THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 


PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 

MRS.  PRUDENCE  W.  KOFOID 


OBSTETRIC    CATECHISM; 

CONTAINING 
,  TWO  THOUSAND  THREE  HUNDRED  AND  FORTY-SEVEN 

QUESTIONS  AND   ANSWERS 


OBSTETKICS  PROPER. 


BY   JOSEPH   WARRINGTON;   M.  D. 


#iie  I^UE^rcts  aElJ  §\it^  Wim\m^\w,%* 


PHILADELPHIA: 

EDMOND    BARRINGTON   AND   GEO.    D.    HASWELL. 

18  5  3. 


Entered  according  to  Act  of  Congress,  in  the  year  1853,  by 
BARRING  TON    &    HA  SWELL, 

in  the  Clerk's  Office  of  the  District  Court  of  the  United  States,  in 
and  for  tlie  Eastern  District  of  Pennsylvania. 


CONTENTS 


Accouchee — Arrangements    of    the 

chamber  and  bed  of  144 

After  pains  1' 
Alterations  in  the  os  and  cervix  uteri    ( 

Amenorrhoea  316 

Varieties  of  318 
Treatment  of 
From  physical  causes 
Duties  to  be  performed  in 
Anatomy  of  the  female  pelvis 
Anterior  half  of 

Posterior  half  of  20 

Animal  life  of  the  fetus  dormant  100 
Axis  of  the  pelvis 

Ballottement,  how  performed  115 

Bandage — adjustment  of  163 

Bed — arrangement  of  144 

When  to  put  patient  upon  it  154 

How  to  put  patient  up  in  165 

Blood-vessels — of  the  genitalia  44 
Body  of  Fetus— how   to  manage  it 

when  extruded  before  the  head  182 

Bowels— torpor  of,  after  delivery  176 

Carus'  Curve  29 

Cesarean  Section  304 

Objections  to  it  304 

Time  proper  for  performing  it  305 

Management  of  such  cases  305 

Changes  in  the  mode  of  circulation 

after  birth  96 
Changes  in  the  form  of  the  uterus  66 
Child — mode  of   receiving    and  dis- 
posing of  159 
Attention  to  be  given  to  167 
Washing  167 
Uses  of  bandage  on  169 
Pressing  the  169 
Presentation  of  to  mother  170 
Usual  condition  of,  a  few  days  af- 
ter birth  177 
State  of  bovi^els  of  178 
Condition  of  skin  of  178 
Chlorosis  324 
Treatment  of  32>J 
Coccyx  15 
Conception  59 
Convulsions  234 
Classification  of  234 
Hysteric,  symptoms  of  234 
Apoplectic,  symptoms  of  235 
Treatment  in  cases  of  236 
Cord,  tying  and  dividing  the  159 
Dressing  the  168 
Decadence  of  the  178 
What  to  do  with  it  in  pelvic  pre- 
sentations 182 
Prolapse  of  225 
Too  short  a  226 
Corpus  Lutuum  55 


Cranium — composition  of 

Ovoid  form  of 

Fontanellesin 

Sutures  in 

Vertex  of 

Diameters  of 

Compressibility  of 

Mensuration  of 

Too  large  from  any  cause 
Cranial  surfaces,  form  of 
Cranial  bones,  how  to  remove 
Craniotomy 
Crotchet,  how  used 
Decidual  membrane 
Decidua  uteri  and  decidua  reflexa 
Delivery — clearing  patient  after 

Treatment  of  patient  immediate- 
ly after 

Usual  changes  in  the  condition 
of  the  woman  after 

Getting  up  after 

Premature  artificial 
Dimensions  of  the  fetal  skeleton 
Diameters  of  the  cranium 
Dysmenorrhoea 

Symptoms  of 

Causes  of 

Treatment  of 
Embryo 

Accidents  to 
Ergot  • 

Sometimes  inert 

Not  proper  in  pelvic  deformities 
Fallopian  Tubes 
Fecundation 
Fetus 

Accidents  to  in  utero 

Animal  life  dormant  in 

Anencephalous,  West's  case  of 

Doublets  or  triplets 

Double  fetus,  Thom's  case  of 

Osseous  system  of 

Physiol  tgical  characters  of  the 

Viability  of 

Weight  of 
Fetal  Ellipse 
Fetal  Heart  and  circulation 

Skeleton,  dimensions  of 
Females,  Physiological  and  Patholo- 
gical condition  during  the  repro- 
ductive life  of 

Hygienic  rules  for 
Flexion,  how  to  assist 
Fontanelles 

Functions  of  the  genital  organs 
Genitalia 

Infiammation  of  the 
Generation 
Getting  up 

8 


101 
102 
103 
103 
104 
104 
107 
107 
226 
102 
292 
283 
292 
71 
74 
162 


170 

303 

101- 

104 

327 

328 

3'29 

a-o 


238 
302 


414 
luO 
42J 
227 
415 
100 


66 
176 


Mtimem 


CONTENTS. 


Hymen 

Ilydrometra 

Head  too  large  226 

Causes  arresting  it  above  the  su- 
perior strait  230 
Husband — Duty    of  Physician  and 

Nurse  to  171 

Hemorrhage  at  or  shortly  after  ter- 
mination of  labor  239 
Management  of                                240 
How  to  prevent  it  by  anticipa- 
tion                                             240 
Concealed                                        241 
Labor — Precursory  signs  of                  119 
Action  of  uterus  in                        120 
Bag  of  waters  in                              122 
Action  of  accessory  powers  in      123 
Different  stages  of                           124 
Physical  inquiry  into    the    fact 

or  progress  of  150 

Relation  of  the  diflFerent  stages 

of 

General  classification  of  130 

Prognosis  of  by  touch  126 

When  to  be  put  to  bed  for  the 

completion  of  154 

Average  duration  of  126 

Conditions  incident  to  the  differ- 
ent stages  of  127 
General  classification  of                 130 
Presentation  and  position  of  the 

child's  head  in  131 

Classification  of  presentation  in  131 
Grand  varieties  of  occipital  posi- 


tion ii 


131 


Particular  positions  of  cephalic 

exti-emity  in ,  132 

Flexion  in  135 

Rotation  in     „  135 

Extension  in  136 

Restitution  in  137 

Rotation  of  the  shoulders  in  138 
Two  main  points  to  be   studied 

in  the  mechanism  of  142 

Additional  positions  of  head  in  142 
Convertibility  of  the  positions  in  142 
Movements     executed    on    the 

shoulders  in  142 

Duties  of  physician,  nurse  and 

patient  in  second  stages  of         154 
What  to  do  when  the  head  has 

passed  through  the  vulva  in    157 
Complicated  with    prolapsion  of 

the  bladder,  vagina,  &c.  230 

Dr.  B's  case  of  Hernia  of  intes- 
tines into  the  perinteal  cul-de- 
sac  231 
Complicated  by  lesions  of  func- 
tion of  the  nervous,  vascular, 
or  muscular  system  232 
Complicated  with  incapacity  for 

spontaneous  delivery  248 

Instrumental  surgery  in  249 

Classification  of  obstetric  instru- 
ments to  be  used  in  249 
Forceps  in                                         250 
Cases  for  the  use  of  forceps  in      253 


Labor — Position  of  patient  for  the 

use  of  forceps  in  253 

Mode  of  application  of  forceps  in  254 
Ligature  on  the  forceps  handles 

in  256 

Principle  of  action  of  the   for- 
ceps in  256 
Forceps  in  1st  position  of  the- 

head  in  257 

Forceps  in  2d  position,  in  258 

Forceps  in  posterior  position  in    258 
Forceps  in  transverse  positions 

of  head  in  259 

Forceps  in  mento-anterior  cases 

of  face  in  261 

Forceps  in  breech  presentation 

in  .  261 

Dr.  Hodge's  Modification  of  For- 
ceps to  be  used  in  262 
Dr.  Bond's  remarks  on  Forceps    267 
Complicated  with    distortion  of 

the  pelvis  280 

Mode  of  measuring  distortions 

previous  to  285 

Mode  of  delivery  in  cases  of  pel- 
vic distortion  287 
Craniotomy  for  the  termination 

of  288 

How  to  use  instruments  for  crar 

niotomy  in  291 

How  to  aid  the  collapse   of  the 

cranium  in  291 

Veetis  in  these  cases  of  291 

Crotchet  in  292 

How    to    remove    the     cranial 

bones  in  292 

Dr.  Hodge's  Compressores  Cranii 

in  296 

Version  by  the  feet  in  cases  of 

deformity  of  the  pelvis  in  302 

Professor  Simpson's  arguments 

in  favor  of^— in  302 

Accidents  in  third  stage  of  305 

Management  of  such  cases  in      305 
Management  of  the  cord  when 

ruptured  in  306 

Retention  of  the  placenta  in         306 
Management    of    the    placenta 

when  retained  in  ■  306 

Coagula  between  the  uterus  and 

placenta  in  307 

What  to  do  in  such  ca.ses  in  307 

Leucorrhoea  333 

Causes  of  334 

Difficulties  of  diagnosis  of  334 

Character  of  the  discharge  .335 

Chronic  335 

Treatment  of  333 

Vaginal  339 

Chronic  341 

Ligaments,  anterior  and  posterior  of 

the  uterus  50 

Lochia  175 

Lying-in    room— admission  of  com- 
pany into  171 
Medicine  and  surgery  of  the         187 
Menstruation  51 


CONTENTS. 


Menstruation— termination  of  53 
Menstrual  functions — disorders  of  316 
Absence  of  316 
Varieties  of  amenorrhoea  318 
Treatment  of  do.  319. 
Milk  175 
Menorrhagia  331 
Causes  of  332 
Treatment  of  332 
Nerves  of  the  uterus  and  its  appen- 
dages 44 
Obliquity  of  the  uterus  229 
Os  innominatum  16 
Osseous  system  of  the  fetus  100 
Os  uteri,  sometimes  difficult  to  find  229 
Alteration  in  from  pregnancy         60 
Contraction  of  on  the  placenta  308 
Ovaries                                                     48 
Ovum,  constitution  of                              75 
Patient,  treatment  of  after  delivery  173 
Pelvis — Anatomy  of  the  female             13 
Anterior  half  of                                 19 
Axis  of                                                28 
Contents  of  the                                  30 
Inclined  Planes  of                             26 
Posterior  half  of                                20 
Proper                                               21 
Perinaeum                                                38 
Applying  napkins  to  163 
Physical  Exploration — to  detect  preg- 
nancy 112 
Arrangement  of  patient  for  it  114 
Inquiry  into  the  fact  or  progress 

of  labor  150 

Time  and  manner  of  making  it  153 

Physiological  characters  of  the  fetus    97 

Physomelra  379 

Treatment  of  380 

Placenta  82 

Management  of  161 

How  to  promote  delivery  of  161 

How  to  receive  and  dispose  of  it  162 

Tardy  delivery  of  305 

Retention  of  306 

Management  of  retention  of  306 

Retention  of  from  contraction 

of  OS  uteri  308 

How  to  act  in  such  cases  308 
Mianagemont  when  the  cord  is 

ruptured  306 
Coagula  between  the  uterus  and  307 
What  to  do  in  such  cases  307 
Retention  of  from  irregular  con- 
traction of  the  uterus  310 
Hour-glass  contraction  ol  311 
Adhesion  of  the  312 
How  to  treat  it  312 
Consequence  of  failure  to  extract 
the  812 
Planes  inclined  26 
Presentation  and  position  131 
Classification  of  131 
Second  class  of  179 
Diagnosis  of  pelvic  180 
Different  positions  of  pelvic  180 
Mechanism  of  labor  in  pelvic  181 
Of  anterior  fontanelles  193 
Classification  of  face  200 
1* 


Presentation— Cases    proper   to  be 

converted  into  face  202 

Of  side  of  the  head  218 

Of  Cephalic  extremity  132 

Bringing  down  the  feet  in  breech  221 
Deviations,  always  rectify  them 
Deviated  breech  221 

Diagnosis  of  pelvio  180 

Instrumental  delivery  in  shoul- 
der 216 
Pelvic,  subdivisions  of  184 
Of  the  shoulders  211 
Classification  of,  in  shoulder  211 
Rules  for  the  band  with  which 

to  correct  deviation  of  214 

How  to  rectify  them  221 

Fillet  in  222 

Blunt  hook  in  223 

Position  of  the  shoulder  212 

Further  inquiries  respecting  di- 
agnosis of  217 
Changes  of  in  the  early  part  of 

labor  218 

Other  deviations  of  219 

Position  of  umbilicus  92 

Position  and  presentation  131 

Grand  varieties  of  131 

How  to  convert  one  into  another  190 
Pregnancy  59 

Alteration  of  size  and  position 
of  the  pelvic  and  abdominal 
viscera  caused  by  68 

Signs  of  108 

Development  of  uterus  caused  by  109 
Physical  exploration  in  112 

Touch  in  113 

Arrangements  for  physical  exa- 
mination in  114 
Ballottement  in  115 
Ausciiltation  in  116 
Condition  of  vagina,  urine,  &c.,  in  118 
Duration  of  119 
Diseases  incident  to  387 
Plethora  in  388 
Consequences  of  plethora  in  388 
Fever  from    nervous   irritation 

during  390 

Best  remedy  for  it  in  390 

Mild  treatment  most  proper  in    391 
Exercise  during  392 

Venesection  in  892 

Catheterism  in  393 

Aperients  in  394 

How  to  treat  hernia  in  395 

Caution  about  dress  in       •  395 

Sympathetic  treatment  Ofirrita- 

tion  in  396 

Pruritis  vulvae  in  396 

Irritation  of  the  bladder,  Ac,  in  896 
Care  to  be  taken  of  the  mammae 

in  398 

Hemorrhage    from    the   uterus 

during  400 

Placenta  praevia  in  400 

How  managed  400 

Retroversion  of  uterus  in  402 

Extra  uterine  410 

Treatment  in  extra  uterine  413 


CONTENTS. 


Puerperal  women — usual  changes  in 

the  condition  of 
Quickening 
Reproduction 
Rigidity,  &c. 

Treatment  of 
Rotation — How  to  effect 
Sacrum 
Speculum 
Superfetation 
Sutures  of  the  Cranium 
Thymus  Gland 
Umbilicus — ^Position  of 
Urethra 
Urine 
Uterus 

Alterations  in  neck  and  mouth  of 

Changes  in  form  of 

Condition  of  in  the  second  stage 
of labor 

Obliquity  of— cause  of  deviation 

Obliquity  of 

Irregular  contraction  of 

Treatment  of  irregular  contrac- 
tion of 

Rigidity  of 

Treatment  of  rigidity  of 

Inertia  of 

Treatment  of  inertia  of 

Rupture  of 

Blundell's  instructions  in 

Prolapsus  and  procidentia 

Inversion  of 

Degrees  of  inversion  of 

Diagnosis  of  inversion  of 

Treatment  of  inversion  of 

Cause  of  retention  of  the  pla- 
centa 

Irritable 

Treatment  of  irritable 

Displacement  of 

Symptoms  of  displacement  of 

True  method  of  diagnosis  to  ve- 
rify displacements  of 

Treatment  of  displacements  of 

Pessaries  in  displacements  of 

Manner  of  introducing  pessaries 
in  displacements  of 

Objections    to    pessaries  in  dis- 
placements of 

Prolapsus  of 

Ordinary  causes  of  prolapsus  of 

Bandages  and  compresses  in  dis- 
placements of 

Autevcrsion  of 

Retroversion  of 

Symptoms  of  retroversion  of 

Partial  or  incomplete  retrover- 
sion of 

Causes  of  retroversion  of 

Treatment  of  retroversion 

Professor  Meigs'  instrument  in 
retroversion  of 


Uterus — Dr.    Henry  Bond's  instru- 
ment in  retroversion  of  the       359 
Retroflexion  of  the  363 

Tumors   in,  or  springing  from 

the  363 

Not  always  easily  diagnosticated 

in  the  303 

Treatment  of  tumors  in  the  3C4 

Polypus  of  the  364 

Treatment  of  polypus  of  the        366 
Inflammation  of  the  367 

Symptoms  of  inflammation  of 

the  367 

Modes  of  termination  of  the  in- 
flammation of  368 
Abscess  of  1  he  368 
Treatment  of  acute  inflamma- 
tion of  369 
Ulceration  of  the  370 
Best  mode  of  recognition  of  371 
Treatment  of  ulcers  of  the  373 
Malignant  ulceration  of  373 
Diagnosis  of  malignant  ulcers  of  374 
Treatment  of  malignant  ulcers 

of  the  375 

Cancer  of  the  376 

Treatmentofcancer  of  the  377 

Cauliflower  excrescence  of  the     378 
Treatment  of  the  cauliflower  ex- 
crescence of  the  379 
Vagina  36 
Vaginitis                                                   340 
Different  stages  of                          340 
Gonorrhoeal                                     340 
Treatment  of                                  341 
Pain  in  back,  &c.,  not  always  de- 
pendant upon                             342 
Vectis  or  lever                                         188 
Manner  of  using  it                         189 
Try  to  use  in  presentations  of 

anterior  fontanelle  196 

In  cases  of  craniotomy  291 

Version  by  Head  192 

Different  steps  of  192 

By  the  feet  202 

By  the  feet  in  pelvic  deformity    302 
Simpson's  argviment  302 

Condition  of  mother  favorable  to  203 
Only  while  head  is  within  the 

OS  uteri  203 

Operation  of  203 

I'osition  of  patient  proper  for  it    204 
Rule  for  the  use  of  the  particu- 
lar hand  in  204 
"When  to  act  on  the  breech  only 

in  207 

What  to  do  with  the  cord  in  208 

Spontaneous  213 

Vertex  of  the  cranium  104 

Viability  of  fetus  91 

Vulva— What  to  do  when  the  head 

has  passed  through  it  157 

Weight  of  fetus  92 


INTRODUCTORY  ADDRESS 


TO    MY   OWN     OBSTETRIC     PUPILS,    AND   TO     STUDENTS   OP 
MEDICINE   GENERALLY; 

Gentlemen  :  I  dedicate  this  little  work  to  you. 

Were  I  in  the  midst  of  you,  as  I  present  each  a  copy,  I 
would  address  you  principally  in  the  following  words : 

I  have  designed  this  little  book,  as  an  aid  to  you  in  the 
prosecution  of  your  studies  in  a  very  important  branch  of 
the  science  and  art  of  medicine,  or  as  an  occasional  re- 
membrancer for  you,  when  you  are  engaged  in  the  practice 
of  your  profession,  remote  from  any  experienced  living 
counsellor. 

It  is  written  for  you,  as  a  sort  of  vade  raecum,  or  reviver 
of  your  knowledge  in  this  matter,  and  in  this  respect  as 
far  as  it  goes,  I  am  sure  it  will  be  useful  to  you ;  but  re- 
member, it  is  not  your  text  book :  it  is  your  tes,t  book  :  it  is 
your  catechist  or  inquisitor,  not  to  tell  you  any  thing  new, 
but  enable  you  to  determine  what  you  do,  or  what  you  do 
not  already  know. 

Your  knowledge  of  the  great  principles  on  which  the 
important  subject  of  obstetrics  is  founded,  is  to  be  derived 
from  other  sources ;  from  well  approved  standard  works : 
as  those  written  by  Velpeau,  by  Dewees,  by  Rigby,  by 
Ramsbotham,  by  Churchill,  by  Meigs,  Lee,  &c. ;  and  to  un- 
derstand either,  or  all  of  them  well,  you  must  give  faithful 
attention  to  the  study  of  the  anatomy  of  the  female  pelvis, 
and  all  those  organs  which  are  concerned  in  the  process  of 
conception,  gestation,  parturition  and  lactation.  These 
you  must  study  by  personal  application  of  your  scalpel, 
under  the  direction  of  a  skilful  anatomical  teacher. 

Then  follow  closely  upon  the  demonstrations  of  your  Ob- 
stetric Professor  through  his  whole  course — examine  his 
various  pictorial  illustrations,  anatomical  and  physiological 

.   (7) 


8  INTRODUCTOEY  ADDRESS. 

specimens,  and  give  earnest  heed  to  his  demonstrations  of 
the  mechanism  of  the  various  kinds  of  labor  upon  the 
mannikin, — naj,  more  than  this,  embrace  every  possible 
opportunity  to  exercise  yourselves,  either  alone  with  a 
demonstrator,  or  in  small  classes,  till  you  become  familiar 
with  every  variety  of  presentation,  position,  mode  of  cor- 
recting those  which  are  deviated — the  proper  mode  of  per- 
forming version — the  use  of  obstetric  instruments,  &c. 
This  done,  my  little  book  will  be  of  service  to  you,  and  I 
shall  be  gratified,  if,  when  you  use  it  as  a  catechism  of 
your  knowledge  in  midwifery,  you  shall  have  been  so  well 
instructed  by  the  method  I  have  just  pointed  out,  that 
you  may  detect  any  error  which  may  exist,  either  from  want 
of  critical  knowledge  on  my  own  part,  or  which  may  have 
been  inadvertently  committed,  in  the  haste  I  have  made  to 
supply  it  to  those  who  have  demanded  it  of  me  for  your 
sakes,  while,  as  some  of  you  know,  I  have  been  closely  oc- 
cupied, not  only  in  the  ordinary  duties  of  private  practice, 
but  in  teaching  the  science  and  exercising  the  art  of  ob- 
stetrics in  connexion  with  the  Philadelphia  Dispensary, 
Lying-in-Charity,  and  Nurse  Society,  since  the  year  1837, 
to  successive  classes  of  young  men,  in  four  courses  per  an- 
num, of  at  least  sixty  lessons  each;  have  assisted  in  the 
training  of  more  than  three  hundred  and  seventy  advanced 
students  or  recent  graduates  in  medicine;  stationed  them 
by  the  bedsides  of  more  than  two  thousand  parturient  wo- 
men ;  superintended  their  conduct  there  ;  relieved  them  in 
their  embarrassments  and  aided  them  in  their  difficulties ; 
examined  their  clinical  histories ;  superintended  the  prac- 
tical education  of  nearly  one  hundred  nurses;  have  been 
engaged  with  lady  visitors  of  the  Institution  in  deciding 
the  fitness  of  these  candidates  to  enter  upon  their  respon- 
sible duties  of  taking  care  of  parturient  and  puerperal  fe- 
males under  the  direction  of  their  physicians,  and  there- 
fore, little  time  has  been  allowed  me  for  authorship. 

I  have  not  followed  the  systematic  arrangement  adopted 
by  any  obstetric  writer  in  preparing  this  little  offering,  and 
1  have  not  calculated  it  for  the  meridian  of  any  particular 
school. 

The  grand  principles  of  this  science  and  art  are  the  same 
every  where ;  and  from  the  numerous  institutions  for  me- 
dical teaching,  which  have  sprung  up  around  the   parent 


INTRODUCTORY   ADDRESS.  9 

Btalk  throughout  the  different  sections  of  our  wide-spread 
country,  we  may  hope  for  a  powerful  and  honorable  com- 
petition for  excellence  in  the  mode  of  illustrating  these 
principles,  and  the  extension  of  facilities  for  properly  qua- 
lifying the  candidates  to  enter  usefully  upon  the  exercise 
of  one  of  the  most  important  functions  which  one  human 
being  can  exert  towards  another. 

I  have  written  out  the  matter  now  presented  to  you  dur- 
ing the  minutes,  for  I  have  not  hours  of  leisure ;  and, 
therefore,  lay  no  claim  to  great  precision  in  the  language  I 
have  used.  The  questions  are  to  be  taken,  as  though  they 
were  put  to  you  extemporaneously  and  familiarly,  and  the 
answers  are  mostly  made  out  as  though  you  were  unex- 
pectedly called  upon  to  give  them,  and  in  this  I  consider 
consists  some  good  quality  in  the  little  essay  now  put  into 
your  hands. 

It  will  be  perceived  that  I  have  said  much,  or  rather,  al- 
lowed others  to  say  much  respecting  the  various  kinds  of 
forceps  which  they  have  purposed  for  the  benefit  of  the 
child  in  cases  in  which  the  mother  is  found  incompetent  to 
give  it  birth  in  season  to  secure  its  continued  existence, 
and  have  inquired  somewhat  minutely  in  reference  to  the 
character  of  instruments  which  hav^  been  contrived  to 
complete  the  delivery  for  the  mother's  sake  more  especially. 
I  have  done  this,  because,  while  I  continue  to  believe  that 
instruments  of  any  kind  are  comparatively  rarely  needed  in 
cases  of  well  conducted  obstetricy,  it  is  exceedingly  impor- 
tant that  no  man  should  be  allowed  to  enter  upon  this  de- 
partment of  the  profession,  in  any  place  whatever  without 
having  been  first  not  only  shown,  hut  thoroughly  tested  in 
the  mode  of  use  of  the  instruments  which  unfortunately 
may  be  needed  for  the  full  accomplishment  of  all  the  pain- 
ful duties  which  may  devolve  upon  him. 

I  have  thoughtfully  refrained  from  alluding  to  the  sub- 
ject of  anaesthaesia  in  obstetric  practice,  having  not  much 
to  say  from  my  own  experience  in  its  use,  and  after  stat- 
ing my  strong  objection  to  making  women,  even  transiently, 
drunk,  whenever  any  substitute  may  be  successfully  avail- 
able, I  have  still  preferred  not  to  attempt  in  the  text  to 
prejudice  the  mind  of  the  student  against  any  preceptorial 
or  professorial  biases  he  may  have  received. 

I  have  introduced  into  this  book  the  sentiments  of  a  few 


10  INTRODUCTORY   ADDRESS. 

of  the  .numerous  cultivators  of  obstetric  medicine  now  liv- 
ing— and  I  have  apparently  made  you  draw  some  of  your 
responses  from  a  few  of  the  many  excellent  volumes  which 
have  been  written  on  obstetrics.  I  know  full  well,  young 
gentlemen,  that  during  the  hurried  pupilage,  which  unfor- 
tunately is  the  custom  of  the  present  age,  you  cannot  have 
read  and  reflected  upon  all  that  such  industrious  men  could 
tell  you,  or  have  written  for  you;  but  should  not  the  al- 
most unanimous  sentiment  of  the  great  American  medical 
association  influence  you  and  your  successors  to  protract 
the  period  of  your  studentship,  I  pray  that  you  may, even 
after  having  acquired  the  degree  of  the  Doctorate  in  the 
schools  of  your  choice,  before  you  attempt  to  share  largely 
in  those  weighty  responsibilities  which  are  experienced  by 
some  of  your  older  brethren,  embrace  every  possible  op- 
portunity to  make  yourselves  acquainted  with  the  results  of 
their  carefully  made  observations,  either  by  conversation  or 
correspondence  with  those  who  are  now  busy  on  the  stage 
of  professional  life,  or  studying  the  works  of  those  who 
have  fulfilled  their  destiny  here  and  have  gone  hence  to 
receive  their  retribution,  leaving  to  us  a  rich  legacy  in 
their  recorded  sentiments  and  experience. 

Gentlemen — in  the  course  of  a  quarter  of  a  century  de- 
voted to  the  practice  of  medicine,  and  especially  to  that  of 
obstetrics,  I  have  many  times  fuiRy  realized  the  truth  of  the 
assertion  of  the  venerable  Dr.  John  W.  Francis  of  New 
York,  uttered  more  than  thirty  years  ago,  and  which,  on 
the  present  occasion,  I  transmit  to  you. 

^'  Another  circumstance  which  fortifies  the  claims  of  this 
branch  of  study,  arises  from  the  absolute  certainty,  that 
every  one  engaged  in  the  practice  of  medicine,  is  liable  to 
be  called  upon  in  obstetrical  cases.  Although  it  is  per- 
mitted, that  the  practice  of  physic  and  surgery  be  exercised 
by  the  same  individual,  it  is  not  unusual  for  persons  to  se- 
lect that  particular  branch  to  which  their  genius  or  feelings 
are  most  partial.  But,  it  is  proper  for  us  to  bear  in  mind, 
that  whether  emulous  of  medical  or  surgical  reputation,  in 
the  course  of  our  duties,  calls  in  midwifery  happen  to  all. 
To  gentlemen  who  enter  upon  the  practice  of  medicine  in 
this  country,  a  knowledge  of  the  obstetric  art  is  indispens- 
able. Cases  of  labor  occur  in  every  well  regulated  family, 
and  calls  of  this  nature  can  neither  be  parried  or  delayed. 


INTRODUCTORY   ADDRESS.  11 

Our  wide-spread  population  is  little  favorable  to  that  divi- 
sion of  the  profession  which  elsewhere  obtains,  and  what  is 
regulated  by  common  consent,  is  not  to  be  controlled  by 
individual  feeling. 

"  To  studious  and  ingenuous  youth,  our  science  presents 
attractions  in  no  wise  inferior  to  any  other  branch  of  know- 
ledge. The  whole  range  of  physiology  solicits  his  dili- 
gence, and  will  amply  reward  his  toil.  Talents  of  the 
highest  order  have  lately  entered  into  this  field  of  inves- 
tigation, and  the  most  sanguine  anticipations  have  been 
realized. 

"  But,  it  is  not  the  charms  of  philosophy,  nor  an  honest 
ambition  of  fame,  which,  in  this  case,  are  alone  to  be 
consulted.  Considerations  of  prudence,  and  the  claims  of 
humanity,  alike  urge  us  to  the  acquisition  of  this  part  of 
the  profession.  In  no  situation  in  which  the  physician 
can  be  placed,  does  he  encounter  greater  responsibility 
than  in  the  practice  of  midwifery.  The  lives,  both  of 
the  mother  and  child,  are  dependent  on  his  skill,  and 
amid  the  most  trying  and  perplexing  difficulties,  his  char- 
acter is  committed  to  the  tribunal  of  censorious  and 
often  incompetent  judges.  Nothing  but  conscious  ability 
can  arm  his  resolution,  or  protect  his  feelings  from  in- 
sult. Of  that  knowledge  which  lends  its  aid  to  art, 
it  is  not  only  requisite  that  it  be  possessed,  but  that  it  be 
ready  and  forthcoming ;  and  on  the  practice  of  mid- 
wifery above  all  others,  it  is  incumbent,  that  his  know- 
ledge be  present,  and  at  command.  No  where  is  promp- 
titude and  decision  more  required ;  in  no  instance  is  the 
man  of  science  more  distinguishable  from  the  mere  preten- 
tender ;  in  no  situation  is  the  conduct  of  the  physician 
more  the  object  of  present  attention,  or  of  subsequent 
criticism.  In  the  Lying-in-chamber  no  opportunity  is 
afi'orded  for  qualification  or  deliberation.  The  case  de- 
mands immediate  assistance,  and  it  is  vain  to  tempo- 
rise. Vacillation  and  delay,  always  dangerous,  may  here 
prove  fatal.  The  student's  mind  must  be  thoroughly 
prepared,  else  the  imputation  of  ignorance  will  attend  his 
hesitation  and  confusion.  Firmness  and  decision,  founded 
upon  accurate  and  precise  knowledge,  will  alone  secure  to 
him  present  confidence  and   future  approbation." 

I  have  addressed  you  numerous — 2347 — interrogatories ; 


12  INTRODUCTORY   ADDRESS. 

yet  I  have  omitted  many  things — but  should  I  discover  that 
you  profit  well  by  what  I  have  already  done,  1  shall  aim, 
time  permitting,  to  catechise  you  at  some  future  period 
upon  the  whole  subject  of  obstetric  medicine,  which  I  con- 
sider includes  not  only  practical  midwifery,  but  obstetrics 
proper,  and  the  diseases  of  puerperal  and  nursing  women, 
and  young  children. 


Very  respectfully  yours, 

JOSEPH  WARRINGTON. 


No.  229  Vine  Street,  Franklin  Square, 
Philadelphia,  Jan.  1,  1853. 


OBSTETRIC    CATECHISM, 


THE    FEMALE    PELVIS. 

What  part  of  the  osseous  system  of  the  female,  is 
entitled  to  the  greatest  consideration  of  the  practical 
accoucheur  ?     That  portion  called  the  pelvis. 


Fig.  1. 


Where  is  the  pelvis  situated  ?  At  the  lower  ex- 
tremity of  the  trunk,  between  the  last  lumbar  verte- 
bra and  the  upper  portion  of  the  ossa  femora. 

Of  how  many  bones  is  the  adult  pelvis  constituted  ? 
Four. 

What  are  they  ?  One  sacrum,  one  coccyx,  and  two 
ossa  innominata. 

Where  is  the  sacrum  situated  ?  Between  the  last 
lumbar  vertebra  above,  and  the  coccyx  below,  and  be- 
tween the  ossa  innominata  behind. 

2  (13) 


14 


ANATOMY    OF   THE    FEMALE    PELVIS. 


What  is  the  shape  of  the  sacrum  ?     Triangular  or 
pyramidal — concave  anteriorly  and  convex  posteriorly. 

Fig.  2. 


How  many  articulating  surfaces  does  it  present  ? 
Four.  Its  base  above,  for  connection  with  the  lumbar 
vertebra ;  its  apex  below,  for  the  coccyx,  and  one  on 
the  upper  half  of  each  side  for  the  posterior  portion 
of  the  ossa  innominata. 

What  is  found  on  the  anterior  surface  of  the  sa- 
crum ?  Four  or  five  quadrangular  facettes,  with  the 
same  nunjber  of  transverse  lines,  marking  the  point 
of  fusion  of  the  originally  distinct  bones ;  at  the  end 
of  these  transverse  lines  an  equal  number  of  foramina, 
for  the  passage  of  the  anterior  branches  of  the 
sacral  nerves. 

What  muscles  are  attached  to  the  outer  edges  of  the 
sacrum,  and  between  these  holes  ?  The  pyramidal 
muscles. 

What  is  attached  to  the  sharp  edges  of  the  inferior 
half  of  the  sacrum  ?     The  sacro-ischiatic  ligaments. 

What  is  the  general  appearance  of  the  posterior 
portion  of  the  sacrum  ?     Convex,  and  very  rough. 


ANATOMY    OF   THE    FEMALE    PELVIS. 


15 


What  do  we  find  in  the  median  line  ?  Several  spi- 
nous processes. 

What  is  to  be  seen  at  the  upper  portion  of  the  pos- 
terior face  ?  Articulating  surfaces  for  the  last  lumbar 
vertebra. 

What  exists  at  the  lower  portion  ?  A  triangular 
notch,  in  which  terminates  the  spinal  canal. 

What  is  to  be  seen  on  each  side  of  the  spinous  pro- 
cesses of  the  sacrum  ?  Four  or  more  foramina  for  the 
transmission  of  the  posterior  branches  of  the  sacral 
nerves. 

What  is  the  object  of  the  rough  surfaces  near  the 
edges  of  the  posterior  face  of  the  sacrum  ?  To  pre- 
sent points  for  the  strong  attachment  of  sacro-iliac 
and  sacro-ischiatic  ligaments. 

What  is  the  object  of  the  broad  oblique  and  some- 
what rough  surface,  at  the  upper  lateral  portions  of 
this  bone  ?  For  articulation  with  the  ilia  or  inno- 
minata. 

What  is  the  situation  of  the  coccyx  ?  At  the  in- 
ferior termination  of  the  sacrum,-  with  which  it  is  ar- 
ticulated. 

What  is  its  shape  ?     Triangular. 

What  projects  upwards,  or 
backwards,  from  its  base  ?  Two 
prolongations,  resembling  horns. 

What  is  the  shape  of  its  apex  ? 
Tuberculated  and  rounded. 

What  is  attached  to  its  edges  ? 
The  ischio-sacral,  or  short  sacro- 
ischiatic  ligament. 

What  muscles  are  inserted  in- 
to its  edges  ?  The  ischio-coccy- 
geal  muscles. 

What  muscle  is  attached  to  its 
point  ?  The  external  sphincter 
ani  muscle. 

Of  how  many  bones  is  the  coccyx  originally  com- 
posed ?     Three  or  four. 


Fig.  3. 


16 


ANATOMY    OF   THE    FEMALE    PELVIS. 


What  kind  of  articulation  exists  between  the  sacrum 
and  coccyx  ?     Gynglimoid,  or  hinge-like. 

What  is  the  direction  of  the  motion  of  the  coccyx 
upon  the  sacrum  ?     Antero-posterior. 

What  is  the  extent  of  movement  usually  allowed  to 
the  apex  of  the  coccyx  ?  Erom  half  an  inch  to  an 
inch. 

Does  the  presence  of  the  coccyx  necessarily  inter- 
fere with  the  process  of  labour  ?  Only  when  it  is 
partially  or  completely  anchylosed. 

What  is  the  general  shape  of  an  os  innominatum  ? 
It  has  a  very  irregular  quadrangular  shape,  appearing 
as  if  strangulated  at  its  middle,  and  twisted  in  two  op- 
posite directions. 

Fig.  4. 


How  many  surfaces  has  it  ?  Two,  one  external  and 
one  internal. 

What  is  the  arrangement  of  its  internal  surface  ?  It 
is  divided  into  two  nearly  equal  portions  ;  the  upper 
one,  extensively  excavated,  is  called  the  internal  iliac 
fossa. 


ANATOMY    OF   THE    FEMALE    PELVIS.  17 

What  occupies  this  broad  expanse  ?  The  internal 
iliac  muscle. 

What  do  we  find  at  the  posterior  margin  of  this  up- 
per portion  ?  An  articulating  surface  for  junction 
with  a  portion  of  the  sacrum. 

What  is  the  general  shape  of  the  inferior  portion  ? 
Triangular. 

What  opening  exists,  about  the  centre  of  this 
lower  portion  ?  The  obturator  foramen,  or  subpubic 
opening.  ^ 

What  constitutes  the  point  of  division  between  the 
upper  and  lower  portions  of  the  ossa  innominata  ? 
The  linea-ilio-pectinea,  running  from  the  crest  of  the 
pubis,  backwards  towards  the  junction  with  the  sacrum. 

What  is  to  be  observed  on  the  external  or  femoral 
surface  of  the  os  innominatum  ?  First,  the  external 
iliac  fossa  ;  secondly,  the  acetabulum  ;  thirdly,  the 
subpubic,  or  obturator  foramen,  surrounded  by  the 
edges  of  the  pubis,  the  ischium  and  the  ischio-pubic 
ramus. 

What  occupies  the  external  iliac  fossa  ?  The  glutei 
muscles'. 

What  is  noticed  on  the  upper  edge  of  the  os  inno- 
'minatum  ?     The  crest  of  the  ilium. 

What  is  attached  to  this  crest  ?  Muscles  in  its  cen- 
tral portion,  Poupart's  ligament  at  the  anterior,  and 
the  sacro-iliac  ileo  lumbar  ligaments  at  the  posterior 
extremity. 

What  is  seen  on  its  anterior  edge  ?  First,  the  antero- 
superior  spine  of  the  ilium,  next  a  small  semilunar 
notch,  then  the  inferior  anterior  spine  of  the  ilium, 
the  groove  for  the  psoas  and  iliacus  muscles,  then  the 
ileo-pectineal  eminence  for  the  insertion  of  the  psoas 
parvus  muscle,  then  a  triangular  smooth  surface,  the 
spine  of  the  pubis. 

What  is  the  arrangement  of  the  posterior  edge  of 

this  bone  ?     First,  the  posterior  spine  of  the  ilium ;  a 

small  irregular  notch ;  the  posterior  inferior  spine  of 

the  ilium  ;  which  articulates  with  the  sacrum,  then  the 

2* 


18  ANATOMY    OF   THE   FEMALE    PELVIS. 

great  ischiatic  notch,  and  lastly  the  posterior  portion 
of  the  tuberosity  of  the  ischium. 

Of  how  many  distinct  bones  is  the  os  innominatum 
originally  composed  ?  Three,  the  ilium  above,  the 
ischium  directly  below,  the  pubis  in  front  of  the  last, 
and  rather  below  the  first. 

At  what  points  are  these  bones  consolidated  into  one 
at  a  later  period  of  life  ?  In  the  acetabulum,  or  co- 
tyloid cavity,  at  the  pectineal  eminence  and  at  the 
middle  of  the  ischiopubic  ramus. 

At  about  what  period  of  life,  does  this  consolidation 
take  place  ?     The  age  of  puberty. 

What  are  the  principal  articulations  or  symphyses 
of  the  pelvis  ?  One  for  the  two  pubic  bones  to  each 
other  in  front,  and  one  for  each  ilium  to  the  sacrum 
behind. 

What  is  the  mode  of  articulation  of  the  symphysis 
pubes  ?  The  two  articular  surfaces  are  applied  to 
each  other,  and  sustained  firmly  in  that  position,  by 
strong  ligamentous  fibres,  before  and  behind.  Under- 
neath, the  fibrous  arrangement  is  so  abundant,  as  to 
give  to  it  the  character  and  name  of  sub-pubic  liga- 
ment. 

Is  the  symphysis  pubes  of  the  adult  female  suscepti- 
ble of  spontaneous  separation,  or  of  having  one  ex- 
tremity moved  upon  the  other  ?  There  are  strong 
reasons  for  believing  that  no  perceptible  degree  of 
motion  can  be  efi'ected  in  a  healthy  condition  of  the 
parts. 

What  is  the  character  of  the  posterior  or  sacro-iliac 
symphysis  ?  The  sacrum  is  placed  like  an  inverted 
key-stone  at  the  top  of  an  arch,  between  the  two  iliac 
bones  ;  strong  bands  of  ligamentous  fibres  extend 
across  from  the  sacrum  to  the  ilium  on  each  side,  and 
thus  a  strong  fibro  cartilaginous  symphysis  is  effected. 

Is  there  a  bursa,  or  synovial  sac,  found  in  either  of 
these  symphyses  ?  In  the  symphysis  of  the  pubes, 
there  is  to  be  seen  an  approximation  to  a  bursa  ;  it  is 
however  far  from  complete.     In  each  of  the  sacro-iliac 


ANATOMY   OF   THE   FEMALE   PELVIS. 


19 


junctions  there  are  found  some  small  points  of  con- 
densed fatty  matter,  but  no  regular  bursa. 

Does  the  pelvis  derive  support  from  any  other 
points  than  those  at  which  the  bones  are  articulated  ? 
It  is  decidedly  fortified  by  the  addition  of  the  ileo- 
lumbar  ligaments — sacro-iliac  and  sacro-ischiatic  liga- 
ments. 

Where  is  Poupart's  ligament  situated  ?  It  com- 
mences at  the  anterior  superior  spinous  process  of  the 
ilium,  and  extends  to  the  crest  of  the  pubis,  crossing 
to  a  small  extent  beyond  the  symphysis. 

Where  is  the  obturator  membrane  found  ?  Filling 
up  nearly  the  whole  of  the  obturator  foramen,  admit- 
ting merely  of  space  sufficient  to  allow  the  transmis- 
sion of  small  vessels,  nerves  and  muscles. 

If  we  divide  the  pelvis  into  two  equal  parts,  by  a 
section  through  the  acetabula,  what  will  be  found  in 
the  anterior  portion  ?  The  bodies  and  rami  of  the 
pubes,  the  arch  of  the  pubes,  the  rami  of  the  ischia, 
and  the  obturator  foramina. 

Fig.  5. 


What  will  be  found  in  the  posterior  half  ?  The  sa- 
crum and  coccyx,  the  bodies  of  the  ischia  and  ilia, 
sacro-sciatic  notches. 


20 


ANATOMY    OF   THE    FEMALE    PELVIS. 


What  do  the  lateral  portions  of  the  pelvis  include  ? 
The  ischia  and  ischiatic  notches  with  a  part  of  the 
obturator  foramina. 

Fig.  6. 


How  is  the  pelvis  divided  above  and  below  ?  Into 
false  pelvis  above,  and  true  pelvis  below. 

What  forms  the  boundary  line  between  the  two  ? 
The  linea-ilio-pectinea. 

What  is  the  upper  portion  called  ?  Pavilion ;  false 
pelvis  ;  and  abdominal  pelvis. 

What  is  its  general  description  ?  It  is  defective 
directly  in  front,  is  expanded  and  elevated  at  the 
sides,  while  posteriorly  it  is  again  diminished  except 
in  the  central  portion,  where  it  is  somewhat  filled  up 
by  the  promontory  of  the  sacrum  and  the  lower  lum- 
bar vertebrae. 

What  influence  do  these  lumbar  vertebrae,  and  the 
promontory  of  the  sacrum  exert  on  the  position  of 
the  child  ?  They  project  so  far  into  the  cavity  of  the 
abdominal  pelvis  as  to  divide  it  into  two  portions,  and 
cause  the  child  to  slide  off  to  one  side. 

What   is  the  distance  between  the  superior  anterior 


ANATOMY    OF   THE    FEMALE    PELVIS.  21 

spinous  process  of  one  ilium  and  that  of  the  other? 
From  nine  to  ten  inches. 

What  is  the  distance  between  the  middle  point  of 
one  crest  and  that  of  the  other  ?  From  ten  to  eleven 
inches. 

What  is  the  depth  of  the  upper  or  abdominal  pel- 
vis, that  is,  from  the  top  of  the  crista  to  the  linea- 
ilio-pectinea  ?  From  three  and  one  fourth,  to  three 
and  a  half  inches. 

Which  is  of  most  importance  in  obstetrics,  the  su- 
perior or  inferior  pelvis  ?  The  inferior,  or  emphati- 
cally the  pelvis. 

PELVIS  PROPER. 

What  is  its  general  shape  ?  Conoidal,  with  its  base 
upwards. 

What  are  its  principal  openings  ?  -  One  above,  and 
one  below. 

What  are  these  openings  called  ?     Straits. 

Why  ?  Because  they  are  rather  more  contracted 
than  the  space  between  them. 

What  is  the  space  between  the  straits  called?  The 
cavity  or  concavity,  basin,  etc. 

Are  these  straits  just  alluded  to,  not  identical  with 
the  cavity  ?  They  are  the  initial  and  terminal  por- 
tions of  the  true  pelvis,  but  should  always  be  distin- 
guished from  the  cavity  itself. 

What  is  the  shape  of  the  superior  strait  ?  Cor- 
diform,  or  somewhat  elliptic,  with  one  end  of  the 
ellipse  depressed. 

What  constitutes  the  superior  strait  ?  The  top  of 
the  symphysis  pubes,  the  linea-pectinea,  the  linea-ilea, 
and  promontory  of  the  sacrum. 

What  is  the  circumference  of  the  superior  strait  ? 
From  thirteen  inches  to  thirteen  and  a  half. 

W^hat  number  of  diameters  of  this  strait  are  recog- 
nized in  practice  ?     Four. 

What  are  they  ?  First,  antero-posterior,  or  sacro- 
pubic,  measuring  from  four,  to  four  and  a  half  inches. 


22 


ANATOMY   OF   THE   FEMALE    PELVIS. 


Second,  oblique,  from  points  in  tlie  linea-ileo-pectinea 
(c)  diagonally  to  the  sacro-iliac  symphysis,  {g)  measur- 
ing five  inches.  Third,  the  transverse,  or  bis-iliac,  on 
the  transverse  median  line,  from  one  point  of  the  linea- 
ileo-pectinea  (e)  to  the  opposite  (/),  measuring  five 
and  one  fourth  inches. 

Fig.  7. 


What  is  the  direction  of  the  axis  of  the  superior 
Btrait  ?  It  commences  about  the  point  of  the  coccyx  : 
passes  at  right  angles  with  the  plane  of  the  strait 
through  its  centre,  and  would  make  its  exit  through 
the  abdominal  parieties  about  the  umbilicus. 

What  relation  does  this  axis  hold  to  the  pelvis,  and 
to  that  of  the  body  ?  It  is  always  uniform  with  re- 
gard to  the  pelvis,  but  it  is  variable  with  regard  to  the 
body. 

How  is  the  inclination  of  the  superior  strait  best  de- 
fined ?  Professor  Meigs  says,  when  the  woman 
stands  erect,  or  lies  at  length  on  her  back,  the  plane 
of  the  strait  dips  at  an  angle  of  50°  below  the  con- 
jugate diameter.  It  must  clearly  appear  that  the 
plane  of  the  superior  strait  dips  at  a  variable  angle 
in  various  positions  of  the  trunk  of  the  body ;  for  if 


ANATOMY    OF   THE   FEMALE    PELVIS. 


23 


the  subject  be  standing  it  dips  as  above  at  50°  ;  but 
•if  the  trunk  be  inclined  forwards,  the  dip  will  be 
lessened :  or,  if  the  trunk  be  inclined  far  backwards, 
it  may  be  increased.  Now  this  is  an  important  item 
of  obstetrical  knowledge,  since  upon  it  is  founded  our 
advice  as  to  the  decubitus  of  the  patient,  whom  we 

Fig.  8. 


may  direct  to  extend  the  trunk,  or  to  flex  it  more  or 
less,  as  we  may  or  may  not  desire  to  bring  the  plane 
of  the  superior  strait  into  a  position  that  may  favour 
both  the  entrance  of  the  presenting  part  into  the 
strait  and  its  passage  through  it. 


24  ANATOMY   OF   THE    FEMALE    PELVIS. 

By  figure  8,  it  may  be  shown  that  the  plane  may 
give  different  angles  with  the  spine,  according  as  the 
spine  is  brought  more  forward,  or  carried  further 
backwards — {e  e  e)  is  a  circle  of  which  the  diameter 
(6/)  represents  the  inclination  of  the  plane  of  the 
upper  strait  equal  to  an  angle  of  135°  (fee)  which  is 
the  ordinary  altitude  of  the  spinal  column  or  axis  of 
the  trunk.  If  the  patient,  lying  on  her  back,  should 
have  her  shoulders  raised,  so  as  to  carry  her  spine  for- 
ward to  (<?),  equal  to  22.30°,  the  angle  would  be  re- 
duced to  112.30°.  But  if  the  shoulders  should  be 
still  more  elevated  to  {d)  the  axis  of  the  trunk, 
would  be   at  right  angles  to  the  plane  of  the  strait 

Place  the  woman  on  her  left  side  in  bed,  and  by  the 
same  reasoning  the  accoucheur  may  direct  the  patient 
to  modify  the  inclination  or  dip  of  the  inlet  of  the 
pelvis,  by  inducing  her  to  keep  the  spinal  column 
strait  or  curving  it  forwards. 

What  practical  hint  is  derived  from  a  know- 
ledge of  this  variability  ?  That  in  difficult  or  tedious 
labors  we  should  oblige  the  patient  to  incline  her  body 
forward  to  make  its  axis  more  nearly  correspond  with 
that  of  the  superior  strait. 

What  is  the  shape  of  the  plane  of  the  inferior 
strait  ?  It  is  oval,  or  slightly  cordiform,  if  we  allow 
the  coccyx  to  encroach  upon  its  posterior  extremity. 

What  are  the  boundaries  of  the  inferior  strait  ? 
The  sub-pubic  ligament  in  front,  the  rami  of  the  pu- 
bes  and  ischia  on  each  side,  and  the  sacro-ischiatic 
ligaments  and  coccj^x  behind. 

What  is  the  circumference  of  the  inferior  strait  ? 
Twelve  inches. 

From  what  points  do  we  reckon  the  antero-posterior 
diameter  ?  From  the  posterior  portion  of  the  sub- 
pubic ligment,  to  the  point  of  the  coccyx,  or  better 
still,  to  the  apex  of  the  sacrum. 

What  is  the  distance  ?  Four  and  a  half  inches  ; 
(a  to  b)  fig  9. 


ANATOMY   OF   THE    FEMALE    PELVIS.  25 

From  what  points  do  we  reckon  the  transverse  dia- 
meter ?  From  the  posterior  part  of  the  tuberosity 
of  one  ischium,  to  that  of  the  other,  {c  to  d)  fig.  9. 

Fig.  9. 


What  sjnonyme  have  we  for  this  diameter  ?  Bis- 
iscliiatic  diameter. 

What  does  it  measure  ?     Four  inches. 

What  oth(*r  diameters  should  be  remarked  in  the 
inferior  strait  ?     Two  oblique. 

Whence  are  they  measured  ?  From  the  junction 
of  the  ramus  of  the  pubis,  and  the  ramus  of  the 
ischium  on  either  side  across  to  the  centre  of  the 
sacro-ischiatic  ligaments  on  the  opposite  sides,  {e  to  / 
e  to/)  fig.  9. 

What  is  the  space  ?  Four  inches ;  the  same  as  the 
transverse  diameter. 

What  is  the  direction  of  the  axis  of  the  inferior 
strait  ?  Commencing  just  below  the  promontory  of 
the  sacrum,  it  passes  downwards  perpendicularly 
through  the  centre  of  the  plane  of  the  inferior  strait, 
at  the  point  of  intersection  of  the  antero-posterior 
and  transverse  diameters,  and  thus  out  about  the 
posterior  commissure  of  the  undilated,  or  through  the 
centre  of  the  dilated  vagina. 
3 


26  ANATOMY    OF   THE    FEMALE    PELVIS. 

What  is  the  difference  between  the  transverse  dia- 
meters of  the  superior  and  inferior  straits  ?  The 
transverse  diameter  of  the  superior  strait  is  one  half 
or  three  fourths  of  an  inch  longer  than  that  of  the 
inferior  strait. 

If  we  push  back  the  coccyx,  and  thus  make  the  an- 
tero-posterior  diameter  of  the  inferior  strait  equal  to 
tliat  of  the  oblique,  or  transverse  of  the  superior  strait, 
with  what  body  might  we  compare  the  cavity  of  the 
pelvis  ?  That  of  a  cylindroid,  twisted  one  sixth  of  its 
circumference  upon  its  axis. 

What  are 'the  supero-inferior  measurements  of  the 
pelvis  ?  From  the  top  of  the  symphysis  to  the  lower 
edge  of  the  sub-pubic  ligament,  one  and  a  half  inches. 
From  the  top  of  sacrum  to  the  point  of  coccyx,  five 
inches  ;  when  the  coccyx  is  pushed  back,  from  five 
and  a  half  to  six  inches.  From  the  linea-ilio-pectinea 
to  the  tuberosity,  three  and  a  half  inches  ;  from  the 
crest  of  ilium  to  the  bottom  of  tuberosity  of  the 
ischium,  seven  inches. 

What  is  the  distance  from  the  bottom  of  the  sub- 
pubic ligament  to  the  top  of  the  promontory  of  the 
sacrum  ?     Four  and  a  half  inches. 

What  is  the  distance  from  the  bottom  of  sub- pubic 
ligament  to  the  hollow  of  the  sacrum  ?  Four  and  three- 
fourth  inches  to  five  inches. 

What  is  the  distance  from  the  bottom  of  the  tube- 
rosity of  one  ischium  to  the  linea-ilio-pectinea  directly 
opposite  ?     Six  inches. 

What  is  the  height  of  the  arch  of  the  pubes,  from  a 
line  drawn  on  a  level  with  the  tuberosities  of  the  is- 
chia  ?     Two  inches. 

INCLINED  PLANES. 

Into  what  peculiar  arrangement  is  the  interior  of 
the  pelvis  distributed  ?  On  each  side  of  the  antero- 
posterior median  line  are  found  two  lateral  inclined 
planes. 

What  is  the  direction  of  the  anterior  inclined  planes 


ANATOMY   OF   THE    FEMALE    PELVIS. 


27 


on  each  side  ?  Commencing  nearly  or  exactly  at  the 
sacro-iliuc  symphysis,  they  occupy  all  the  space  be- 
tween that  point  and  the  symphysis  pubes,  and  pass- 
ing downwards  and  forward  just  in  front  of  the  spines 
of  the  ischia,  over  the  obturator  foramina,  they  termi- 
nate on  the  anterior  edge  of  the  rami  of  the  pubes 
and  ischia,  and  at  the  symphysis  of  the  pubes ;  the 
space  between  A,  B,  and  C,  fig.  10,  represents  the 
right  anterior  inclined  plane. 

Fig.  10. 


What  is  the  arrangement  of  the  posterior  inclined 
planes  ?  Commencing  at  the  sacro-iliac  junctions,  at 
or  below  the  linea-ilio-pectinea,  they  occupy  the  space 
between  those  points  and  the  middle  line  of  the  sa- 
crum, then  pass  downwards  and  backwards  behind 
the  spines  of  the  ischia,  over  the  sacro-sciatic  fora- 
mina and  sacro-ischiatic  ligaments,  to  terminate  upon 
the  posterior  edges  of  the  tuberosities  of  the  ischia, 
the  lower  edges  of  the  sacro-ischiatic  and  coccygeo- 
ischiatic  ligaments,  and  also  the  point  of  the  coccyx. 

Which  of  these  occupies  the  greater  space  in  tho 


28 


ANATOMY   OF   THE   FEMALE   PELVIS. 


pelvic  canal,  the  anterior  or  posterior  inclined  planes  ? 
The  anterior,  being  both  longer  and  wider. 

What  influence  do  these  planes  exert  upon  the  me- 
chanism of  labor?  Rotation.  They  direct  the  pre- 
senting part  of  the  fetus.  Thus  if  the  occiput  happen 
to  be  brought  in  contact  with  the  pelvis  anterior  to  the 
spine  of  the  ischium,  it  must  pass  down  upon  the  an- 
terior inclined  plane,  and  emerge  under  the  arch  of  the 
pubes  ;  but  if  the  occiput  happen  to  enter  the  pelvis 
behind  the  spine  of  the  ischium,  the  posterior  inclined 
plane  compels  it  as  it  passes  down,  to  rotate  into  the 
hollow  of  the  sacrum,  that  it  may  escape  at  the  pos- 
terior commissure  of  the  vulva. 

AXIS  OF  THE  PELVIS. 
Regarding  the  pelvis   as  constituted  of  a  series  of 
planes,  extending  from  the  sacrum  to  the  pubes,  from 


ANATOMY    OF   THE   FEMALE    PELVIS.  29 

the  linea-ilio-pectinea  to  the  coccyx  and  sub-pubic  lig- 
ament, how  can  we  represent  the  axis  of  the  pelvis  ? 
As  a  curved  line,  resembling  that  of  a  catheter  adapted 
to  the  adult  male,  as  shown  in  fig.  11,  where  (BB)  rep- 
resents the  prolonged  axis  of  the  superior  strait,  (AA) 
that  of  the  inferior  strait,  (EE)  the  plane  of  inferior 
strait  prolonged  beyond  the  arch  of  the  pubes ;  (GF) 
the  plane  of  the  superior  strait,  somewhat  extended, 
while  the  several  lines  radiating  from  (G)  represent 
the  planes  of  difi"erent  segments  of  the  cavity  of  the 
pubes,  then  the  curved  line  (FF),  passing  at  right 
angles  through  the  several  planes  represents  the 
curve  of  the  catheter,  while  the  extended  line  to  (B), 
represents  the  straight  portion  of  the  catheter,  as  sug- 
gested. 

Who  has  most  beautifully  delineated  the  curved 
direction  of  the  axis  of  the  various  ^acro  and  coccy- 
pubal  planes  of  the  pelvis  ?  Professor  Carus  of  Dres- 
den. 

How  should  you  describe  it  ?  Set  one  leg  of  a  pair 
of  compasses  in  the  middle  of  the  posterior  edge  of 
the  symphysis  pubes  of  a  bisected  pelvis  as  in  the  ac- 
companying figure  12 — the  other  leg  of  the  instru- 
ment being  opened  to  the  distance  of  the  semidia- 
meter  of  the  sacro-pubal  diameter  of  the  superior 
strait.  Commencing  at  this  point  in  the  diameter,  de- 
scribe a  circle.  Extend  the  sacro-pubal  diameter  by 
a  dotted  line,  till  it  reaches  the  circumference ;  from 
the  end  of  the  coccyx,  a  little  extended,  produce  a 
line  to  the  end  of  the  pubes,  then  continue  it  dotted 
till  it  reach  the  outer  periphery  of  the  circle : — draw 
also  a  line  from  the  centre  of  the  concavity  of  the 
sacrum  through  the  inner  periphery  to  the  centre. 
Continue  this  as  a  dotted  line  to  the  outer  periphery. 
It  will  be  found  that  these  three  dotted  lines  will  meet 
precisely  in  the  same  point  in  the  outer  periphery. 
This  circle,  according  to  Carus,  will,  for  all  ordinary 
purposes,  sufficiently  faithfully  represent  the  axis  of 
the   various   sacro-pubal,   coccy-pubal   and   perinseo- 


80  ANATOMY    OF   THE    FEiMALE    PELVIS. 

pubal  planes  of  the  pelvis.  It  is  in  the  line  of  this 
curve  that  the  centre  of  any  body  will  be  propelled, 
during  its  passage  through  the  pelvis. 


Fig.  12. 


Of  what  value  to  practical  midwifery  is  a  know- 
ledge of  this  disposition  of  the  axis  of  the  pelvis  ?  It 
is  indispensible  to  success  and  safety  in  all  manual  in- 
strumental operations,  whether  for  the  delivery  of  the 
fetus  or  placenta. 

What  are  the  general  points  of  difference  between 
the  pelvis  of  the  female  and  the  male  adult  ?  The 
capacity  of  the  female  pelvis  is  greater  than  that  of 
the  male,  its  diameter  being  larger,  though  its  depth 
is  less.  In  the  male,  the  arch  is  narrow  and  high, 
while  in  the  female  it  is  broad,  low,  and  well  formed. 

OF  THE  CONTENTS  OF  THE  FEMALE  PELVIS. 

What  muscles  line  the  upper  pelvis  ?  The  iliaci 
interni  and  the  psose  muscles. 

What  are  the  origin  and  insertion  of  the  iliacus  in- 
ternus  muscles  ?  They  rise  from  the  anterior  two- 
thirds  of  the  crest  of  the  ilium,  in  front  of  the  psose 
muscles,  and  filling  up  the  iliac  fossa,  are  inserted  with 
the  psoas  muscles  into  the  small  trochanter  of  the 
femur. 

In  what  respect  do  these  muscles  affect   the  diame- 


ANATOMY    OF   THE   FEMALE    PELVIS.  31 

ters  of  the  superior  strait  in  the  recent  pelvis  ?  They 
diminish  the  lateral  and  oblique  diameters  from  one 
fourth  to  one  half  of  an  inch. 

Which  diameter  is  the  longer  in  the  recent  pelvis — 
the  oblique  or  transverse  ?  Ramsbotham  says  the  ob- 
lique— Hodge  the  transverse  diameter,  while  Cazeaux 
declares  that  the  oblique  diameters  are  not  diminished 
in  length  by  the  presence  of  the  muscles. 

What  muscles  and  fascia  line  and  close  up  the  infe- 
rior strait  of  the  pelvis  ?  The  pelvic  fascia,  including 
the  internal  iliac  vessels  and  branches*— the  internal 
obturator  and  part  of  the  levatores  ani,  transversus 
perinei,  and  ischio- coccygeal  muscles. 

What  are  the  origin  and  insertion  of  the  levatores 
ani  muscles  ?  They  arise  from  the  inner  part  of  the 
pubes,  the  superior  part  of  the  obturator  foramen,  and 
the  spine  of  the  ischium.  Inferiorly  the  middle  and 
anterior  fibres  unite  beneath  the  rectum,  envelop- 
ing this  intestine,  and  they  are  inserted  into  the 
sphincter  ani  and  perineum  in  front. 

What  is  to  be  understood  by  the  phrase,  "  floor  of 
the  pelvis  ?"  All  the  tissues  found  extending  from 
the  lower  part  of  the  pelvis,  and  closing  more  or  less 
the  inferior  strait.  It  is  composed  of  the  levator  ani 
and  ischio  coccygeal  muscles,  which  constitute  the 
superior  plane,  and  which  is  concave  above ;  the  sphinc- 
ter-ani,  transversalis  perinaei,  ischio-cavernosus  and 
sphincter  vulvae  muscles,  and  the  aponeuroses,  which 
are  less  resisting  in  the  female  than  in  the  male,  com- 
pose the  inferior  plane  of  the  floor  of  the  pelvis.  The 
pubic  vessels  and  nerves  with  cellular  membrane  and 
the  integuments  complete  this  floor. 

What  is  observed  on  the  antero-posterior  median  line 
of  the  exterior  surface  of  the  floor  of  the  pelvis  ?  The 
raphe  of  the  perinseum,  the  point  of  junction  of  the  sev- 
eral constituent  tissues  of  the  perinaeum,  and  one  whose 
rigidity  in  some  cases,  as  well  as  its  relative  feeble- 
ness, subjects  it  to  the  risk  of  laceration,  under 
powerfully  distending  forces. 


32 


ANATOMY   OF  THE   CONTENTS 


What  influence  may  the  constituents  of  this  pelvic 
floor  exert  upon  the  process  of  labor  ?  They  may, 
owing  to  the  rigidity  of  the  parts  or  spasm  of  the  mus- 
cles, retard  the  exit  of  the  presenting  part  of  the  child. 

What  viscera  are  contained  in,  and  attached  to,  the 
pelvis  ?  The  rectum  behind,  the  bladder  in  front,  the 
uterus  and  its  appendages  in  the  middle  and  lateral 
portions  of  the  cavity.  The  vagina,  and  other  por- 
tions of  the  organs  of  generation  occupy  the  lower 
portion  of,  and  are  attached  to,  the  pelvis.  Fig.  13 
gives  a  lateral  section  of  the  contents  of  the  pelvis, 
showing  the  rectum  next  the  sacrum  ;  next,  and  in 
the  middle,  the  uterus  and  the  vagina,  and  in  front, 
the  bladder  in  a  state  of  partial  distention. 

Fig.  13. 


GENITALIA,  OR  ORGANS  OF  GENERATION. 

Do  we  speak  of  the  whole  group  of  organs  of  gene- 
ration in  a  general  or  special  sense  ?  It  should  be  un- 
derstood in  a  general  sense  only. 


OF   THE    FEMALE    PELVIS.  33 

How  are  the  organs  of  generation  classified  ?  Into 
those  of  external,  and  those  of  internal  organs  of  ge- 
neration. 

What  are  called  the  external  organs  ?  Pudenda, 
labia  externa,  clitoris,  nymphse,  orifice  of  vagina,  and 
perinaeuni. 

What  is  usually  included  in  this  list,  though  it  does 
not  pertain  to  generation  ?     The  meatus  urinarius. 

What  is  the  mons  veneris  or  pudenda,  and  where  is 
it  situated  ?  It  is  composed  of  a  dense  fibro-cellular 
adipose  substance,  covering  the  pubes  and  extending 
up  to  a  line  drawn  between  the  anterior  inferior  spinous 
processes  of  the  ilia.  , 

By  what  is  it  covered  ?     By  thick  strong  hairs. 

Where  are  the  labia  externa  situated,  and  how  are 
they  arranged  ?  Commencing  upon  the  front  of  the 
symphysis  pubes,  they  extend  doAvnwards  and  back- 
wards to  the  perinaaum  ;  they  are  thick  and  prominent 
at  their  upper  portion,  but  gradually  diminish  and  be- 
come flattened  as  they  pass  towards  their  posterior  ter- 
mination. 

What  are  the  anterior  and  posterior  points  of  junc- 
tion of  the  labia  called  ?  The  anterior  and  posterior 
commissures  of  the  vulva. 

What  is  the  texture  of  the  labia  ?  Principally  cel- 
lular and  vascular. 

What  kind  of  investment  has  the  labia  ?  It  is  cu- 
ticular  but  passing  into  the  mucous  state. 

What  are  the  boundaries  of  the  vulva  ?  They  em- 
brace all  the  parts  immediately  surrounding  the  genital 
fissure. 

What  is  found  within  the  upper  half  of  the  labia 
majora  ?  The  nymphse,  or  labia  minora,  or  the  labia 
interna. 

What  is  the  situation  of  the  labia  minora  or  nymphse  ? 
They  arise  from  nearly  the  same  point  at  the  anterior 
commissure,  and  pass  obliquely  downwards  and  back- 
wards about  an  inch,  and  then  are  lost  in  the  general 
lining  of  the  labia  externa. 


34  ANATOMY  OF  THE  CONTENTS 

What  is  the  general  shape  of  the  nymphse  ?  Tri- 
angular. 

What  modifications  of  size  or  shape  are  they  inci- 
dent to  ?  In  the  infant  they  are  always  comparatively 
large ;  and  they  may  become  greatly  elongated  and 
enlarged,  and  consequently  sufier  much  alteration  in 
shape  at  later  periods  of  life. 

Is  a  knowledge  of  this  enlargement  of  consequence 
to  the  practitioner  ?  Enlarged  nymphse  may  be  en- 
tangled within  the  obstetric  forceps  and  be  torn,  or 
otherwise  they  may  embarrass  the  use  of  instruments. 

What  is  the  anatomical  structure  of  the  nymphse  ? 
It  is  cellular,  very  vascular,  and  has  the  properties  of 
an  erectile  tissue. 

What  kind  of  external  covering  has  it  ?  A  very  de- 
licate dermoid,  or  perhaps  mucous  membrane. 

What  is  to  be  found  at  the  superior  extremity  of 
the  nymphae  ?  A  little  hemispherical  body,  called  the 
glans  clitoridis. 

What  is  this  glans  the  termination  of?  The  clitoris, 
which  appears  to  be  a  rudimental  penis. 

In  what  respect  does  it  differ  from  the  male  organ  ? 
It  is  much  less  than  it,  and  has  no  corpus  spongiosum 
urethrse. 

What  overhangs  the  glans  clitoridis  ?  A  fold  of 
membrane,  called  the  preputium  clitoridis. 

How  low  do  the  nymphge  descend  ?  To  the  middle 
of  the  orifice  of  the  vagina  nearly. 

What  is  the  space  between  the  nymphse  called  ? 
The  vestibulum. 

What  are  the  characters  of  the  vestibulum  ?  It  is 
a  smooth,  triangular  surface,  covering  the  facette  of 
the  symphysis  pubes  and  is  bounded  on  each  side  by 
the  base  of  the  nymphge,  having  the  clitoris  as  its  apex, 
and  a  line  drawn  from  the  lower  terminal  extremity  of 
one  nymphge  to  that  of  the  other,  through  a  perforated 
caruncle. 

What  is  that  tubercle  or  caruncle  called?  The 
meatus  urinarius,  or  orifice  of  the  urethra. 


OF   THE    FEMALE    PELVIS.  f& 


URETHRA. 

What  is  the  position  of  the  urethra,  with  regard  to 
the  arch  and  symphysis  of  the  pubes  ?  Mostly  imme- 
diately below  the  one  and  behind  the  other. 

Is  the  tubercle  or  caruncle  of  the  urethra  always 
well  developed  and  easily  to  be  recognized  by  the 
touch  ?  Considerable  variety  is  observable  in  the  in- 
vestigation of  many  cases.  Sometimes,  for  example, 
the  orifice  is  very  thin,  merely  membranous.  Some- 
times, it  is  very  patulous  and  funnel  shaped. 

Does  the  urethra  pass  off  in  a  strait  or  curved  line 
from  the  body  of  the  bladder  ?  In  a  line  curved  down- 
wards and  forwards. 

What  circumstances  may  modify  the  direction  of  the 
orifice  and  the  course  of  the  canal  ?  ,  In  some  degrees 
of  prolapse  of  the  uterus  or  vagina,  the  urethra  is  more 
curved — in  extreme  cases  it  is  nearly  inverted — while 
in  advanced  pregnancy,  retroversion  of  the  uterus,  or 
in  cases  of  enlarged  pelvic  tumors  it  is  often  drawn 
up  tightly  behind  the  symphysis  of  the  pubes. 

How  long  is  the  female  urethra  ?     About  one  inch. 

By  what  is  it  lined  ?     Mucous  membrane. 

In  what  direction  do  the  folds  of  the  mucous  mem- 
brane of  the  urethra  run  ?  Longitudinal  and  not 
usually  transverse. 

What  is  there  in  the  female  urethra,  analogous  to 
the  prostatic  portion  in  the  male  ?  A  thickened  con- 
dition of  the  vagina,  anteriorly,  and  a  developement 
of  the  cellular  membrane  on  the  posterior  part  of  the 
urethra. 

What  is  to  be  found  at  the  orifice  of  the  urethra  ? 
A  little  caruncle  generally,  sufficiently  prominent  to 
offer  some  resistance  to  the  touch  of  the  finger. 

What  little  folds  exist  in  the  canal  of  the  urethra  ? 
Folds  of  mucous  follicles,  which  are  sometimes  con- 
siderably developed. 

What  is  the  general  shape  of  the  empty  bladder  in 
the  female  ?     Globular. 


36  ANATOMY  OF  THE  CONTENTS 


VAGINA. 

What  is  found  immediatelj  below  the  meatus  urina- 
rius  ?     The  orifice  of  the  vagina. 

What  are  the  boundaries  of  the  orifice  of  the  va- 
gina ?  All  that  portion  just  in  front  of  the  part  em- 
braced within  the  sphincter  vagina  muscle. 

What  is  the  vulvo-uterine  canal  ?  It  is  the  vagina, 
a  canal  leading  from  the  vulva  to  the  uterus. 

What  muscle  surrounds  the  vagina  near  its  ori- 
fice ?     The  sphincter  vaginae. 

What  are  its  origin  and  insertion  ?  It  arises  from 
the  posterior  portion  of  the  vagina  near  the  perinaeum, 
thence  it  runs  up  the  sides  of  the  vagina  near  its  ex- 
ternal orifice  opposite  to  the  nymphae,  and  covers  the 
corpus  cavernosum  vaginae,  and  is  inserted  into  the 
crus  and  body  of  the  clitoris,  on  each  side. 

What  influence  can  it  exert  ?  It  is  often  feeble,  but 
sometimes  so  powerful  as  to  close  firmly  the  anterior 
portion  of  the  canal. 

What  is  the  length  of  the  vagina,  or  vulvo-uterine 
canal?  From  four  to  six  inches.  Sometimes  it  is 
much  less  than  this. 

What  is  its  direction  in  the  pelvis  ?  It  is  curved  up- 
wards. 

What  are  the  directions  of  its  long  diameters  ?  At 
its  external  extremity  the  long  diameter  is  in  the  di- 
rection of  the  genital  fissure,  antero-posterior — near 
its  middle  the  long  diameter  is  transverse  and  longer 
tlian  the  first,  while  at  the  upper  part  it  is  still  longer. 

What  is  the  length  of  the  antero-posterior  diameter 
of  the  orifice  of  the  vagina  ?  From  half  an  inch  to 
an  inch,  in  its  undistend»3d  state. 

Is  the  vagina  susceptible  of  becoming  much  en- 
larged ?  Not  only  may  its  circumference  be  increased 
to  that  of  the  cavity  of  the  pelvis  during  parturition, 
but  it  may,  and  sometimes  does  become  sufficiently 
large  and  long  to  contain  the  entire  fetus  between  the 
uterus  and  the  vulva,  during  part  of  the  parturient  eff'ort. 


OF   THE   FEMALE   PELVIS.  37 

What  part  of  the  vagina  has  most  sensibility  ?  The 
external  orifice,  just  at  the  point  of  union  or  transition 
of  dermoid  and  mucous  tissues. 

What  is  the  anatomical  structure  of  the  vagina  ? 
Cellulo-fibrous,  with  a  mucous  lining  membrane. 

Whence  is  the  mucous  secretion  furnished  in  the  va- 
gina ?  From  a  large  number  of  mucous  follicles  ar- 
ranged within  the  canal. 

What  is  the  arrangement  of  the  lining  mucous  mem- 
brane ?  Arborescent — though  some  of  the  folds  are 
longitudinal,  particularly  those  anterior  and  posterior, 
while  others  are  transverse,  and  are  sometimes  called 
columns  of  the  vagina. 

What  supply  of  blood-vessels  has  the  vagina  ?  Be- 
sides the  arteries  which  carry  blood  to  it,  the  canal  is 
nearly  surrounded  by  a  plexus  of  veins. 

In  what  respect  is  the  texture  of  the  vagina  differ- 
ent from  that  of  the  nymphse  ?  It  is  non  erectile,  and 
some  portions  of  it  probably  contain  thin  muscular  fibres. 

What  is  the  condition  of  the  vagina  in  the  virgin  fe- 
male ?  It  is  small,  and  near  ifcs  orifice  is  partially  closed 
by  a  duplication  of  lining  membrane  called  the  hymen. 

HYMEN. 

What  is  the  shape  of  the  orifice  of  the  hymen  ?  It 
IS  variable.  Sometimes  triangular ;  sometimes  oval, 
round,  lunated,  and  even  cribriform,  or  pierced  with 
several  holes. 

Is  it  always  present  In  the  virgin  female  ?  It  is 
sometimes  perhaps  congenitally  absent,  but  most  pro- 
bably because  it  has  been  destroyed  in  infancy  by  in- 
judicious management  in  washing  and  wiping  the  parts. 

Is  it  ever  thrown  so  completely  across  the  orifice  of 
the  vagina  as  to  close  it  up  entirely  ?  In  some  cases 
this  condition  is  found  to  exist. 

About  how  far  within  the  vulva  is  the  hymen  in  the 
adult  female  ?     Half  an  inch. 

What  becomes  of  the  hymen  after  it  is  ruptured  ? 
The  lacerated  surfaces  cicatrize,  and  form  several  little 
4 


38  ANATOMY   OF   THE   CONTENTS 

eminences  upon  the  surface  of  the  vagina,  which  have 
been  called  carunculge  mjrtiformes. 

Is  it  a  settled  matter  that  all  the  mulberry-like  ca- 
runcles are  formed  in  this  way  ?  Velpeau,  at  least, 
thinks  that  two  or  more  of  them  exist  originally  and 
independently  of  this  cicatrization  of  the  ruptured  por- 
tions of  the  hymen. 

What  is  found  at  the  inferior  portion  of  the  hymen 
and  anterior  to  it  ?  A  depression,  called  the  fossa  na- 
vicularis. 

What  is  its  inferior  boundary  ?  The  frenum  labio- 
rum,  frenulum  perinei,  or  the  fourchette. 

PERINEUM. 

What  is  found  posterior  to  the  orifice  of  the  vagina  ? 
The  perinseum. 

How  long  is  it  when  undistended  ?  About  one  and 
a  half  inch. 

To  what  extent  may  the  term  perinseum  be  applied  ? 
To  every  portion  of  the  distensible  parts  found  at  the 
inferior  opening  of  the  female  pelvis. 

What  is  the  shape  of  the  perinseum  ?  As  usually 
described  it  is  triangular. 

What  are  its  boundaries  ?  As  viewed  by  some  ob- 
stetricians, as  including  all  the  distensible  parts  of 
the  inferior  opening  of  the  pelvis,  its  boundaries  should 
be  those  of  the  inferior  strait  of  the  pelvis. 

What  is  the  composition  of  the  perinseum  ?  Several 
muscular  layers,  as  the  transversus  perinaei,  the  leva- 
tores  and  sphincter  ani  muscles,  &c.,  then  a  con- 
siderable portion  of  distensible  cellular  and  dermoid 
tissue,  &c. 

Of  what  degree  of  dilatation  is  the  perinasum  sus- 
ceptible ?  Nearly  or  quite  sufficient  to  cover  the  head 
of  the  child  when  extruded  beyond  the  inferior 
strait. 

What  may  be  seen  in  the  recent  female  subject,  if 
the  anterior  parietes  of  the  abdomen  and  the  intes- 
tines  are    removed  ?     The   bloodvessels   and   the  vis- 


OF   THE    FEMALE    PELVIS. 


39 


cera  of  the  pelvis.  Thus  in  fig.  14,  are  seen  at  A,  the 
aorta ;  B,  vena  cava ;  C,  one  of  the  internal  iliac  ar- 
teries descending  into  the  cavity  of  the  pelvis  ;  D  and 
E,  one  of  the  external  iliac  arteries  and  veins  ;  F,  G, 
the  psoas  muscles  ;  H,  the  rectum  ;  I,  the  fundus  of 
the  uterus ;  K,  the  urinary  bladder. 

Fig.  14. 


UTERUS. 

What  kind  of  organ  is  the  uterus  ?  It  is  a  gestative, 
not  a  generative  organ. 

What  is  the  particular  shape  of  the  uterus  ?  Pyri- 
form,  or  conical,  somewhat  flattened  antero-posteriorly. 

Which  is  the  flatter  surface,  the  anterior  or  the  pos- 
terior ?     The  anterior. 

For  general  purposes  of  description,  what  shape  may 
we  assume  for  the  uterus  ?     Triangular. 

How  many  sides  and  angles  has  it  ?  Three  sides 
and  three  angles. 

What  go  off"  from  the  superior  angles  ?  Two  ap- 
pendages called  fallopian  tubes. 

What  name  is  given  to  the  part  above  these  tubes  ? 
Fundus  of  the  uterus. 

What  proceed  from  the  antero-lateral  surfaces  just 


40 


ANATOMY    OF   THE    CONTENTS 


below  the  fallopian   tubes?     The  round,  anterior  or 
utero-pubal  ligaments. 

Fig.  15,  B,  shows  the  portion  of  the  uterus  which 
projects  into  the  vagina ;  H,  the  vagina,  opened  on 
its  upper  or  anterior  portion,  and  spread  out  laterally  ; 
C  C,  represent  the  fallopian  tubes,  the  fibriated  ex- 
tremity of  one  of  which  is  shown  at  D  ;  E  E  indicate 
the  ovaries ;  while  F  points  to  the  right  ovarian  liga- 
ment, which  for  convenience  is  here  shown  as  above 
the  fallopian  tube ;  G  G,  the  segment  of  the  round 
anterior  or  superpubal  ligaments. 

Fig.  15. 


What  portion  is  called  the  body  of  the  uterus  ?  All 
that  part  between  the  superior  angles  and  the  cylin- 
drical portion ;  in  other  words,  all  the  truly  triangular 
portion  of  the  whole  organ. 

What  portion  is  called  the  neck  ?  All  the  cylindri- 
cal portion. 

What  covers  the  uterus  externally  ?     Peritonaeum. 

What  is  meant  by  the  terms  broad  ligaments  of  the 
uterus  ?  They  are  lateral  expansions  of  peritonoeuin 
from  the  sides  of  the  uterus  towards  the  lateral 
and  posterior  portions  of  the  inner  surfaces  of  the 
pelvis. 


OF   THE   FEMALE    PELVIS.  41 

What  is  the  shape  of  the  cavity  of  the  uterus  ?  Tri- 
angular. 

What  relation  do  the  anterior  and  posterior  portions 
of  the  walls  of  the  uterus  hold  to  each  other  ?  They 
are  so  nearly  in  contact,  that  there  is  very  little  space 
between  them. 

What  is  found  at  each  angle  of  this  cavity  ?  The 
orifice  of  each  fallopian  tube  at  the  two  upper  angles, 
and  the  internal  mouth  of  the  uterus  at  the  lower 
angle. 

What  kind  of  lining  membrane  has  the  cavity  of 
the  uterus  ?     It  appears  to  be  a  mucous  membrane. 

How  is  it  ascertained  that  the  lining  consists  of  a 
mucous  membrane  ?  Both  from  its  physiological  func- 
tions and  its  pathological  derangements. 

What  cavity  is  situated  below  the,  internal  orifice 
of  the  uterus  ?     The  cavity  of  the  neck. 

What  is  the  shape  of  this  cavity  ?  It  is  somewhat 
elliptical,  or  barrel  shaped. 

What  is  the  arrangement  of  the  lining  or  internal 
surface  of  the  neck  ?     Arborescent. 

What  are  found  in  the  folds  of  the  neck  ?  A  num- 
ber of  mucous  follicles  formerly  called  ovula  nabothi. 

What  is  the  character  of  the  external  mouth  of  the 
uterus  ?  It  is  somewhat  elliptical,  with  its  longer  di- 
ameter transverse ;  it  presents  an  anterior  and  a 
posterior  smooth  rounded  lip,  and  more  or  less  pro- 
minent. 

Which  of  these  lips  is  the  larger  ?  The  anterior  is 
larger  and  broader  than  the  posterior. 

What  is  the  usual  shape  of  the  orifice  of  the  uterus 
in  the  virgin  female  ?     Rounded  and  very  small. 

At  A,  fig.  16,  is  represented  the  fundus  of  the  ute- 
rus ;  B,  the  triangular  cavity.  All  the  internal  geni- 
talia having  been  cut  in  two,  so  that  the  cut  surface 
of  the  anterior  half  is  here  shown.  B  is  the  triangular 
cavity,  which  as  may  be  observed,  terminates  in  the  bar- 
rel-shaped neck  with  the  arborescent  arrangements  of 
its  internal  lining,  c.  D  D  gives  a  view  of  the  inte- 
4* 


42  ANATOMY    OF   THE    CONTENTS 

rior  of  the  fallopian  tubes,  E  E,  the  fringelike  extre- 
mities. 

Fig.  16. 


How  may  we  distinguish  one  which  has  been  the 
subject  of  one  or  more  pregnancies  or  deliveries  ?  By 
the  fact  that  it  is  more  elliptical  and  somewhat  jagged 
at  the  internal  edges  of  the  lips  of  the  external  os 
uteri. 

What  technical  name  is  sometimes  given  to  the  ex- 
ternal OS  uteri?  That  of  os  tineas,  from  its  resem- 
blance to  the  mouth  of  a  tench  fish. 

How  is  the  vagina  reflected  from  the  os  uteri  ?  An- 
teriorly it  passes  off  so  directly  and  apparently  at 
right  angles,  that  the  anterior  lip  appears  to  be  on  a 
level  with  it.  Posteriorly  it  passes  off  in  a  duplica- 
tion from  near  the  middle  portion  of  the  neck,  and 
thus  presents  a  cul-des-ac,  and  at  the  same  time  gives 
an  impression  to  the  finger  that  the  posterior  lip  is 
longer  than  the  anterior. 

How  long  is  the  uterus  ?     Two  and  a  half  inches. 

How  wide  at  the  upper  angles  ?  One  and  a  half 
inches. 

What  is  the  length  of  the  neck  ?     One  inch. 

What  is  the  thickness  of  the  uterus  ?  Its  body  is 
nearly  an  inch  thick. 

What  sensation  should  a  healthy  living  uterus  com- 
municate to  the  touch  ?  The  os  tincse  should  present  a 
smooth  surface  with  regular  surface  of  lips,  and  about 


OF  THE  FEMALE   PELVIS. 


4» 


the  density  of  a  dead  uterus  hardened  in  alcohol,  or 
an  impression  similar  to  that  of  the  tip  of  the  nose. 

What  is  the  texture  of  the  uterus  ?  It  is  essentially 
fibrous,  but  susceptible  of  great  development  during 
pregnancy. 

From  what  circumstance  do  we  infer  the  exist- 
ence of  muscular  fibres  in  the  uterus  ?  The  pheno- 
menon of  alternate  contractions  during  parturition. 

What  has  been  observed  by  Professor  Hodge,  of  the 
direction  in  which  the  fibres  contract  during  the 
effort  to  expel  the  placenta  ?  That  they  flatten  the 
uterus  and  shorten  its  antero-posterior  diameter. 

What  is  the  arrangement  of  the  muscular  fibres  ? 
They  appear  to  originate  in  a  median  line,  at  the 
front,  back  and  sides  of  the  uterus,  and  to  run  off 
towards  the  fallopian  tubes  and  round  ligaments,  &c. 

Where  are  the  circular  fibres  distributed  ?  About 
the  neck,  and  around  the  upper  angles  or  cornua  of 
the  uterus. 

Fig.  17. 


Who  has  best  succeeded  in  demonstrating  the  ar- 
rangement of  the  muscular  fibres  ?  The  late  Ma- 
.dame  Boivin  of  Paris. 


44  ANATOMY    OF   THE    CONTENTS 


BLOOD  VESSELS  OF  THE  INTERNAL  ORGANS  OF 
GENERATION. 

What  arteries  supply  the  internal  genital  apparatus 
with  blood  ?    The  spermatic  and  hypogastric  arteries. 

Do  these  two  vessels  distribute  their  blood  equally 
to  all  parts  of  the  uterus  and  ovaries  ?  The  sperma- 
tics,  after  sending  branches  to  the  tubes  and  ovaries, 
pass  on  to  the  uterus  to  anastomose  freely  with  the 
ulterior  uterine  branches  of  the  hypogastrics;  the 
greater  portion  of  blood  in  the  upper  part  of  the  ute- 
rus is  furnished  by  the  spermatics,  while  the  hypogas- 
trics alone  supply  this  fluid  to  the  body,  neck  and  the 
vagina. 

How  are  the  uterine  veins  distributed  ?  The  veins 
of  the  uterus,  which  constitute  portions  of  the  sper- 
matic tracts  passing  from  the  inner  to  the  outer  sur- 
face, form  a  great  net-work  in  the  muscular  tissue  of 
the  organ  as  is  shown  in 

Fig.  18. 


NERVES  OF  THE  UTERUS  AND  APPENDAGES. 

From  what  sources  do  the  uterus  and  its  appen- 
dages derive  its  nervous  filaments  ?  From  the  great 
sympathetic    and  the  intercostal  nerves. 


OF   THE   FEMALE    PELVIS. 


45 


To  whose  patient  and  laborious  investigation  are  we 
principally  indebted  for  the  best  illustration  of  the 
distribution  of  the  nerves  upon  the  internal  organs  of 
generation  ?  To  Dr.  Robert  Lee,  who  has,  in  con- 
junction with  the  history  and  demonstration  of  the 
nerves  of  the  uterus,  given  the  accompanying  diagrams 
and  explanations,  which  show  the  posterior  and  late- 
ral view  of  the  gravid  uterus  in  the  fourth  month  of 
pregnancy,  of  the  vagina,  rectum,  and  bladder,  with 

Fig.  19. 


their  ganglia  and  nerves.  A,  the  fundus  and  body  of 
the  uterus  covered  with  peritoneum.  B,  the  vagina. 
C,  the  bladder.    D,  the  rectum.    E  F,  the  ovaries.    G, 


46  ANATOMY   OF   THE   CONTENTS 

the  great  sympathetic  nerve,  where  it  divides  into  the 
two  hypogastric  nerves  and  plexuses.  The  arteries 
and  veins  of  the  great  sympathetic  are  all  injected  in 
the  preparation  from  which  the  drawing  has  been 
made.  A  little  above  the  bifurcation  of  the  great 
sympathetic  nerve  there  is  a  deposit  of  cineritious 
matter  in  its  substance,  and  the  nerve  itself  is  en- 
larged as  high  as  the  kidneys.  H,  the  right  and  left 
hypogastric  nerves  and  plexuses.  The  artery  of  the 
right  is  injected,  and  accompanies  the  nerve  to  the  great 
ganglion  at  the  cervix,  in  which  it  terminates.  I,  the 
left  hypogastric  or  great  utero-cervical  ganglion,  with 
an  artery  passing  into  it  near  the  centre.  J,  the  third 
and  other  sacral  nerves,  sending  numerous  larga 
branches  into  the  posterior  border  of  the  ganglion, 
and  the  whole  of  its  outer  surface.  K,  the  hemorr- 
hoidal nerves  accompanying  the  arteries  to  the  rec- 
tum, and  sending  numerous  branches  to  anastomose 
with  nerves  sent  off  from  the  posterior  edge  of  the 
ganglion.  L,  branches  of  nerves  with  ganglia  sent 
off  from  the  left  hypogastric  nerve,  which  pass  down 
on  the  inside  of  the  ureter  to  the  trunks  of  the  ute- 
rine artery  and  veins,  and  enter  ganglia  which  sur- 
round these  bloodvessels.  M,  the  left  ureter,  with  a 
nerve  accompanying  it,  which  passes  into  the  vesical 
ganglion,  situated  on  the  anterior  part  of  the  ureter. 
N,  rings  of  nerve,  surrounding  the  uterine  bloodves- 
sels. 0,  the  middle  vesical  ganglion,  into  which  large 
nerves  enter,  which  are  sent  off  from  the  anterior 
of  the  left  hypogastric  ganglion,  and  pass  on  the  out- 
side of  the  ureter.  P,  broad  flat  ganglia,  formed  on 
the  great  plexus  of  nerves  which  covers  the  upper 
part  of  the  vagina.  Q,  the  orifices  of  the  divided 
veins  of  the  vagina,  which  are  completely  encircled 
with  ganglionic  plexus  of  nerves.  E,  filaments  of  va- 
ginal nerves  passing  under  the  sphincter.  S,  large 
nerves  covering  the  posterior  wall  of  the  vagina,  and 
anastomosing  with  the  hemorrhoidal  nerves. 


OF   THE   FEMALE    PELVIS. 


4T 


What  is  represented  on  the  anterior  and  latter 
faces  of  the  uterus  dissected  for  this  purpose  ?  A, 
the  right  hypogastric  nerve.  B,  the  sacral  nerves. 
C,  the  right  hypogastric  ganglion.     D,  nerves  from 

Fig.  20. 


the  hypogastric  nerve  to  the  ganglia  on  the  bloodves- 
sels of  the  uterus.  E,  ganglia  surrounding  the  ute- 
rine arteries  and  veins.     F,  ganglionic  plexus,  under 


48  ANATOMY    OF   THE    CONTENTS 

tlie  peritoneum  on  the  fore  part  of  the  uterus.  G, 
filaments  from  this  plexus  passing  out  with  the  round 
ligament.  H,  the  round  ligament.  I,  the  right  ureter 
and  trunk  of  the  vaginal  and  vesical  veins  surrounded 
with  nerves.  J,  ganglia  and  nerves  of  the  vagina. 
K,  nerves  passing  between  the  vagina  and  rectum. 
L,  ganglia  and  nerves  of  the  bladder.  M,  vaginal 
nerves  passing  into  the  bladder  around  the  ureter. 
N,  bloodvessels  and  nerves  of  the  upper  part  of  the 
bladder.  0,  plexus  of  nerves  under  the  peritoneum 
on  the  left  side  of  the  uterus,  the  bloodvessels  of 
wdiich  have  not  been  injected.  P,  filaments  from  this 
plexus  passing  out  with  the  round  ligaments.  Q,  the 
peritoneum  of  the  anterior  part  of  the  body  and  cer- 
vix of  the  uterus  reflected  upwards,  to  expose  the 
ganglionic  plexuses  situated  below. 

OVARIES. 

Where  are  the  ovaries  situated  ?  In  the  folds  of  the 
lateral  or  broad  ligaments,  at  a  little  distance  from  the 
uterus,  one  on  each  side. 

"What  office  do  these  bodies  perform  ?  They  mature 
for  fecundation,  the  germ  of  the  new  being. 

How  are  they  connected  with  the  uterus  ?  By  a  liga- 
mentous attachment  only.  They  project  from  the  pos- 
terior portion  of  the  broad  ligament,  but  are  covered 
by  it  and  are  suspended  only  by  one  edge. 

What  is  the  shape  of  the  ovaries  ?  They  are  oval 
bodies,  slightly  flattened  antero-posteriorly. 

What  is  the  usual  size  of  the  ovaries  ?  Rather 
smaller  than  the  testicles  of  the  male. 

What  other  investment  have  they  beside  the  perito- 
naeum ?     A  proper  tunica  albuginea. 

What  is  the  texture  of  this  coat  ?  Sometimes  thick, 
sometimes  thin. 

What  is  found  in  the  parenchyma  of  the  ovary, 
after  the  seventh,  eighth,  or  ninth  year  of  female  life  ? 
Ten,  twenty  or  thirty  or  more,  little  bodies  called  the 
Graafian  vesicles. 


OF   THE   FEMALE    PELVIS.  49 

What  are  the  vesicles  ?  The  capsules,  which  con- 
tain the  ovules. 

FALLOPIAN   TUBES. 

How  long  are  the  fallopian  tubes  ?  From  four  to 
five  inches. 

What  is  their  general  shape  ?  That  of  a  trumpet, 
having  the  small  end  at  the  angles  of  the  uterus,  and 
the  larger  floating  free  in  the  cavity  of  the  pelvis. 

What  is  the  general  arrangement  of  the  cavity  of 
the  fallopian  tubes  ?  At  their  termination  in  the  uterus 
the  duct  or  canal  is  large  enough  to  admit  of  a  middle 
sized  probe,  it  then  diminishes  towards  the  middle,  so 
that  at  this  part  scarcely  a  bristle  could  pass  along 
it,  after  which,  it  continues  to  increase  somewhat 
irregularly,  until  it  acquires  a  diameter. of  two  or  three 
lines. 

What  is  the  outer  extremity  called  ?     The  pavilion. 

What  is  the  peculiar  mode  of  termination  of  the 
fallopian  tubes  ?  They  have  a  digitated  or  fimbriated 
extremity  caJled,  the  corpus  fimhriatum,  or  morsus 
diaholi. 

What  direction  do  the  tubes  take  in  the  cayity  of 
the  pelvis  ?  They  go  ofi"  nearly  horizontally,  but  are 
exceedingly  tortuous,  and  curve  backwards,  and  to- 
wards the  ovary,  to  some  part  of  which  the  largest 
of  the  fimbriae  is  sometimes  attached. 

What  is  the  anatomical  structure  of  the  tubes  ?  Its 
principal  tissue  is-fibrous,  having  perhaps  some  mus- 
cular fibres  interspersed.  It  is  lined  by  mucous  mem- 
brane and  covered  by  a  peritonaeal  coat. 

Into  what  cavity  do  the  fallopian  tubes  open  ? 
Into  the  cavity  of  the  pelvic  portion  of  the  perito- 
naeum. 

In  what  part  of  the  female  system  do  the  mucous 
and  serous  tissues  unite  ?  At  the  fimbriated  extremity 
of  the  fallopian  tubes. 

5 


50  CONTENTS    OF    THE    FEMALE    PELVIS. 


ANTERIOR   AND  POSTERIOR  UTERINE    LIGAMENTS. 

What  other  ligaments  has  the  uterus  besides  the 
"broad  ligaments  ?  The  anterior,  or  round  ligaments, 
and  the  posterior,  or  utero-sacral  ligaments. 

What  are  the  points  of  origin  and  insertion  of  the 
round  ligaments  ?  They  arise  from  the  superior  part 
of  the  body  of  the  uterus,  just  below  and  a  little  in 
advance  of  the  fallopian  tubes,  and  pass  horizontally 
forwards  through  the  abdominal  canal,  to  be  distri- 
buted beneath  the  mens  veneris,  upon  the  bodies  and 
symphysis  of  the  pubes. 

Where  are  the  posterior  uterine  ligaments  situated  ? 
They  spring  from  the  posterior  portion  of  the  neck 
near  its  middle,  and  diverging,  they  ascend  towards 
the  middle  portion  of  the  lateral  edges  of  the  sacrum, 
and  are  lost  in  the  cellular  membrane  which  covers  that 
bone. 

With  what  are  all  the  uterine  and  ovarian  ligaments 
invested  ?     Peritonaeum. 

In  what  direction  do  the  nerves,  blood-vessels, 
and  absorbents  reach  the  uterus  and  appendages  ? 
Through  the  folds  of  the  peritonaeum  or  the  lateral 
ligaments. 

Does  the  peritonaeum  extend  below  the  posterior 
part  of  the  neck  of  the  uterus  ?  It  is  not  only  spread 
over  the  whole  of  the  posterior  part  of  the  uterus, 
but  also  upon  the  vagina  to  nearly  or  quite  one  third 
of  its  entire  length,  and  thus  makes  a  peritoneal  cul- 
de-sac  in  consequence  of  its  being  reflected  back  from 
that  point  upon  the  rectum. 

What  precaution  should  the  knowledge  of  the  ex- 
treme tenuity  of  the  vagina  and  its  proximity  to  the 
large  serous  sac,  suggest  to  the  mind  of  the  obstetric 
physician  ?  Delicacy  of  manipulation  in  all  cases 
which  requires  that  a  hand  or  instrument  should  be 
^  introduced  along  this  portion  of  the  canal  into  the 
uterus. 


MENSTRUATION.  M 

FUNCTIONS  OF  THE  GENITAL  ORGANS. 

What  is  the  condition  of  the  internal  organs  of  ge- 
neration in  the  fetus  ?  Thej  are  very  small,  the  ute- 
rus is  almost  lost  in  the  broad  ligaments.  The  same 
may  be  said  of  the  ovaries. 

At  about  what  age  do  the  ovaries  appear  to  become 
vascular  ?     Seven  years. 

What  physiological  changes  have  taken  place  at 
the  period  of  life  called  puberty  ?  All  the  internal 
organs  have  become  more  developed,  more  vascular ; 
the  uterus  has  acquired  greater  size,  and  is  more  soft ; 
the  mons  veneris  is  covered  by  hair;  there  is  an 
increased  flow  of  blood  to  the  pelvic  viscera,  and  to 
the  head ;  the  face  becomes  more  or  less  flushed ;  the 
voice  is  altered,  and  the  moral  sensibility  is  more 
acute. 

At  what  period  of  life  do  these  changes  occur? 
At  the  fourteenth  or  fifteenth  year  in  temperate  cli- 
mates. 

What  function  is  the  genital  organs  then  capable  of 
performing  ?     That  of  reproduction. 

MENSTRUATION. 

What  function  does  the  uterus  actually  perform 
when  all  these  physical  changes  have  regularly  oc- 
curred?    That  of  menstruation. 

What  is  to  be  understood  by  the  function  of  mens- 
truation ?  That  in  which  the  uterus  at  regular  periods 
secretes  a  certain  amount  of  sanguinolent  fluid. 

What  are  the  synonyms  of  menstruation?  Cata- 
menia,  menses,  courses,  monthlies^  terms,  monthly 
terms,  monthly  periods,  the  reds,  being  unwell,  indis- 
posed, has  her  troubles,  ^c. 

Whence  is  this  fluid  furnished  ?  From  the  internal 
surface  of  the  uterus. 

What  proof  have  we  that  it  is  derived  from  this 
source  ?  It  is  always  accompanied  by  some  degree 
of  uterine  iritation :  when  occlusion  of  the  orifice  of 


52  MENSTRUATION. 

the  uterus  exists,  the  secretion  is  still  eliminated  l»y 
the  capillaries,  but  retained  within  the  cavity  of  the 
uterus. 

What  are  the  characteristics  of  the  menstrual  fluid  ? 
It  is  a  sanguinolent  fluid,  of  a  peculiar  quality  and 
odour,  of  a  color  usually  between  that  of  venous  and 
arterial  blood ;  it  is  not  coagulable,  nor  does  it  pu- 
trify  readily. 

At  what  periods  of  life  does  this  secretion  usually 
commence  ?  In  hot  countries  from  nine  to  ten  years  ; 
in  temperate  climates,  from  fourteen  to  fifteen  years  ; 
in  cold  regions,  from  eighteen  to  twenty  years. 

At  how  early  a  period  are  females  of  tropical  cli- 
mates known  to  be  capable  of  bearing  children  ?  At 
ten  years  old. 

What  influence  have  these  hot  climates  upon  the 
continuance  of  the  power  of  reproduction  ?  Females 
who  begin  this  function  early,  also  decline  early. 

What  is  observed  in  this  respect  in  regard  to  cold 
countries  ?  That  the  capability  of  reproduction, 
though  beginning  later,  is  continued  to  a  much  more 
advanced  age. 

What  difference  is  observable  in  the  condition  of 
females  residing  at  the  top,  and  those  at  the  bottom 
of  high  mountains  ?  Those  on  the  top  are  more  tardy, 
but  continue  much  longer,  w^hile  those  at  the  foot, 
have  the  function  of  menstruation  begin  and  end 
much  sooner. 

What  difference  is  observed  between  the  girls  re- 
siding in  a  country  place,  and  those  who  inhabit  large 
cities  ?  That  those  in  the  country  do  not  usually  be- 
gin as  soon  to  menstruate  as  those  who  live  luxuriantly 
in  large  towns. 

What  influence  does  temperament  usually  exert? 
Those  of  a  nervous  temperament  usually  menstruate 
earlier  and  more  abundantly  than  those  of  phlegmatic 
temperament. 

What  are  the  general  symptoms  accompanying  a 
menstrual  effort  ?     An  unpleasant  feeling  of  languor, 


MENSTRUATION.  8% 

"weariness  about  the  loins,  sense  of  fulness  in  the  hypo- 
gastrium,  a  disposition  frequently  to  urinate  and.  defe- 
cate. Sometimes  great  nervous  excitement,  perhaps 
even  hysteria ;  the  breasts  swell  and  feel  more  or  less 
tight  and  painful ;  there  is  headach,  palpitation,  and 
a  peculiar  odour  of  the  breath  in  some  cases. 

What  is  the  usual  color  of  this  fluid  at  the  first 
time  it  is  discharged  ?     Pale  red  or  pink  color. 

How  long  does  the  first  discharge  continue  ?  Some- 
times only  a  few  hours,  and  rarely  ever  more  than 
two  or  three  days. 

At  what  period  do  these  symptoms  and  the  dis- 
charge return  ?     At  the  end  of  one  lunar  month. 

When  the  menstrual  function  is  fairly  established, 
how  many  days  are  usually  occupied  in  the  discharge  ? 
In  temperate  climates  from  five  to  seven  days. 

What  influence  does  the  health  of  the  patient  exert 
upon  the  menstrual  function  ?  Delicate  women  usu- 
ally menstruate  more  abundantly  than  the  more  robust, 
but  in  some  diseases  it  is  altogether  interrupted. 

What  is  the  usual  quantity  discharged  at  each  pe- 
riod ?  In  temperate  climates,  probably  from  four  to 
six  ounces.  In  tropical  climates,  from  ten  to  fifteen 
ounces ;  while  in  frigid  zones,  the  quantity  is  very  small. 

What  is  observed  in  corpulent  women  in  reference 
to  menstruation  ?  That  they  usually  have  a  greater 
discharge  than  those  who  are  thin. 

Is  the  menstrual  function  easily  disturbed  ?  In  those 
of  nervous  temperaments  and  irritable  constitutions,  it 
is  very  easily  disturbed  by  physical  and  moral  causes. 

What  is  the  usual  duration  of  the  menstrual  period 
of  female  life  ?     About  thirty  years. 

TERMINATION   OF  THE  MENSTRUAL  FUNCTION. 

At  what  age  does  this  function  usually  subside  ?  At 
from  forty-five  to  fifty ;  but  much  earlier  in  hot 
countries. 

What   is    the  period  of  female  life  at  which    this 
function  subsides  usually  called  ?     Change  of  life. 
5* 


54  MENSTEJIATION. 

What  is  observed  in  reference  to  the  subsidence  of 
this  function  at  this  period  of  life  ?  It  becomes  very 
irregular,  sometimes  profuse  for  one  time,  then  passes 
over  a  month  or  more,  then  returns  profusely,  and 
finally  subsides  altogether ;  when  slight,  it  is  usually 
painful ;  and  when  profuse  debilitating. 

Into  what  character  of  discharge  does  menstrua- 
tion often  pass  before  it  ceases  altogether  ?  Into  that 
of  a  leucorrhoeal  or  sero-mucous,  or  albuminoid  fluid. 

What  physical  changes  are  observed  to  take  place 
in  the  female  upon  the  arrival  of  this  period  of  her 
life  ?  Her  capillary  circulation  becomes  less  active, 
the  cellular  and  adipose  matters  of  the  mammae  are 
absorbed,  there  is  a  general  shrinking  of  her  person, 
and  that  beautiful  rotundity  of  her  form  disappears. 

What  alteration  does  her  pulse  undergo  ?  It  be- 
comes slower  and  feebler,  and  it  acquires  more  of  a 
congestive,  or  apoplectic  character. 

In  w^hat  respect  is  this  period  to  be  regarded  as  the 
critical  period  of  life  ?  Because  it  is  observed  that 
generally,  if  there  be  no  local  predisposition  to  dis- 
ease, women  usually  have  their  health  improve  after 
the  cessation  of  menstruation :  but  if  strongly  dis- 
posed to  any  malignant  aftection,  this  disease  is  liable 
to  become  more  rapid  in  its  course  to  a  fatal  termina- 
tion. 

What  precise  knowledge  have  we  respectmg  tne 
cause  of  the  function  of  menstruation  ?  None  what- 
ever, notwithstanding  the  numerous  speculations  on 
this  subject.  Until  within  the  last  quarter  of  a  century, 
ideas  of  the  causes  of  the  periodical  flow  of  bloody 
matter  from  the  genitalia  of  females,  were  exceedingly 
vague  and  often  perfectly  absurd.  The  patient  and 
laborious  investigations  of  Purkinje,  Von  Baer,  Pro- 
vost and  Dumas,  Coste,  T.  Wharton  Jones,  Wagner, 
Bischofl",  Raciborski,  Gendrin,  Negrier,  Lee,  Bouchet 
and  some  others,  have  contributed  greatly  towards 
the  establishment  of  the  belief  that  menstruation  is 
dependent  upon  ovulation,  that  it  is  mostly  if  not  al- 


MENSTRUATION.  5S 

ways  coincident  with  the  perfection  of  the  female  germ 
or  ovule,  and  its  separation  from  its  nidus,  the 
Graafian  cell,  to  be  conveyed  into  the  uterus,  when 
should  it  have  become  fecundated  it  would  remain 
during  its  allotted  period  of  gestation,  but  from  which 
it  is  carried  with  the  fluid  eliminated  from  the  mucous 
or  blood  membranes. 

What  condition  does  the  ovary  usually  exhibit  at 
the  menstrual  epoch  ?  One  of  the  Graafian  cells  is 
found  to  be  turgid  and  ready  to  be  ehminated  from 
the  cyst,  or  there  is  to  be  found  a  little  lacerated  spot 
which  is  the  opening  of  a  small  cavity  containing  a 
clot  of  blood. 

CORPUS  LUTEUM. 

What  is  a  corpus  luteum  ?  It  is  a  yellow  body 
found  in  the  ovaries  of  animals  that  have  recently 
been  in  sexual  heat,  and  in  those  of  the  human  fe- 
male, and  shortly  after  they  have  menstruated,  or  be- 
come pregnant. 

What  has  hitherto  been  the  estimate  put  upon  the 
discovery  of  this  yellow  body  in  the  ovary  ?  That 
the  woman  had  surely  eliminated  a  fecundated  germ 
from  the  Graafian  cell  in  which  the  corpus  luteum  was 
found  occupying. 

What  is  the  opinion  of  Professor  Meigs  on  this 
subject  ?  That  the  existence  of  this  yellow  body  in 
the  ovary  is  an  evidence  of  finished  ovulation  and  not 
necessarily  of  fecundation : — that  is,  the  corpus  lu- 
teum exists  in  the  ovary  at  the  close  of  every  mens- 
truation, because  at  that  time  an  ovule  has  been  ma- 
tured, and  separated  from  the  ovarian  stroma,  whether 
it  has  been  fecundated  or  not. 

What  is  his  opinion  of  the  physical  qualities  of  the 
corpora  lutea  ?  That  they  are  vitellary,  in  all  re- 
spects resembling  the  yolks  of  eggs. 

What  is  to  be  found  in  the  Graafian  cells,  by  lay- 
ing them  open  ?     A  small  drop  of  fluid  like  water. 

What  are  the  microscopic  properties  of  the  contents 


66  GENERATION. 

of  a  Graafian  vesicle  ?  A  transparent  fluid  containing 
a  vast  number  of  granules,  surrounding  an  albumin- 
ous fluid,  at  a  point  in  the  periphery  of  the  granular 
layer,  may  be  found  a  spot,  indicated  by  Purkinje, 
and  called  by  him  the  germinal  vesicle.  On  one  side 
of  this  vesicle  is  an  opaque  spot,  called  also  the  ger- 
minal spot.  The  germinal  vesicle  is  about  one  six- 
tieth of  a  Paris  line  in  diameter,  while  the  germinal 
spot  is  from  the  one  hundredth  to  the  one  three  hun- 
dredth of  a  line  in  diameter.  Fig.  21  is  a  diagram 
of  a  section  of  the  Graafian  vesicle  and  its  contents, 
showing,  the  situation  of  the  ovum,  a  represents  the 
granulary  membrane;  5,- the  accumulation,  called  by 
Baer,  the  proligerous  disc,  c,  the  ovum,  or  the  germi- 
nal vesicle ;  the  dotted  lines  running  to  d,  represent 
two  walls,  inner  and  outer  of  the  Graafian  vesicle, 
while  e  points  out  the  indusium  or  sub-peritoneal  tis- 
sue, directly  underneath  which,  again  is  the  stroma 
of  the  ovary  so  condensed  as  to  make  the  tunica  al- 
buginea. 

Fig.  21. 


REPRODUCTION  OR  GENERATION. 

What  is  generation  ?  It  is  the  function  of  repro- 
ducing the  species  after  the  form  originally  impressed 
upon  it.  It  is  therefore  the  function  peculiar  to  ani- 
mated or  living  beings. 

What  is  the  simplest  form  of  generation  ?  Fissi- 
parous  generation,  which  does  not  require  sexual  or- 


GENERATION.  5T 

gans — it  is  in  other  words,  generation  by  spontaneous 
division  ? 

What  is  the  next  higher  grade  or  kind  of  genera- 
tion ?  That  which  is  called  germniparous,  consisting 
in  the  formation  of  buds  or  germs  on  some  parts  of 
the  body,  either  internally  or  externally. 

.  What  are  the  germs  in  the  female  of  the  higher 
order  of  animals  ?  The  ovules,  situated  within  the 
ovarian  vesicles. 

At  what  period  of  life  do  these  germs  in  the  human 
female  exist?  Between  that  of  puberty  and  the 
"  change  of  life." 

W^here  is  the  male  germ  found  in  vegetable  life  ? 
In  the  pollen  of  plants. 

What  is  the  male  germ  in  animals  ?  It  exists  in 
the  fluid  secreted  by  the  testicles. 

What  is  necessary  to  constitute  fecundation  ?  The 
contact  of  the  male  and  female  germs. 

What  may  be  said  of  the  theories  of  generation  ? 
That  they  are  numerous  and  some  of  them  vague,  and 
it  is  true  that  the  whole  subject  is  shrouded  in  an  im- 
penetrable mystery. 

What  are  the  two  principal  theories  in  reference  to 
conception  ?  1.  That  of  epigefiisis,  which  is  probably 
the  oldest,  and  which  supposes  that  it  depends  upon 
the  conjunction  of  the  male  and  female  germs  in  the 
uterus,  and  that  each  contributes  its  portion  to  the 
formation  of  the  new  being.  2.  That  of  evolution, 
in  which  it  is  assumed  that  the  mother  furnishes  the 
entire  molecule,  and  that  the  stimulus  of  the  male 
sperm  only  excites  it  into  vital  activity. 

Which  appears  to  be  the  most  rational  theory  of  ge- 
neration ?  1.  That  of  the  ovulg-r,  in  which  it  is  be- 
lieved that  the  elements  of  the  new  being  reside  in 
the  ovule,  secreted  by  the  ovary.  2.  That  of  evolu- 
tion, in  which  the  sperm  of  the  male  operates  merely 
by  its  stimulus  upon  the  female  germ  or  ovule  within 
the  ovarium. 


58 


GENERATION. 


FECUNDATION. 
Is  the  semen  masculinum,  in  its  totality,  necessary 
to  produce  a  fecundation  of  the  female  germ  ?     Yes. 

What  were  the  experiments  of  Spallanzani,  of  Pre- 
vost  and  Dumas,  in  reference  to  this  ?  They  found 
that  it  was  necessary  that  the  fluid  they  used  for  arti- 
ficial fecundation,  should  contain  the  peculiar  animal- 
cules or  molecules  existing  in  the  semen  masculinum. 

Is  there  any  analogy  in  the  modes  of  fecundation 
in  vegetables  and  animals  ?  The  presence  of  the  pollen 
is  necessary  to  the  developement  of  the  germ. 

How  does  fecundation  take  place  in  the  fish  ?    By  the 

deposite  of  the  male  sperm  upon  the  spawn  of  the  females. 

What  is  the  mode  of  fecundation  in  the  frog  and  other 

of  the  batracian  animals  ?     The  male  sperm  is  thrown 

upon  the  female  eggs,  as  they  pass  from  her  body. 

Is  a  true  copulation  necessary  in  the  mammiferous 
animals  ?     Yes. 

Is  it  necessary  that  the  male 
germ  be  deposited  within  the  fe- 
male body  ?     It  is. 

Is  it  most  probable  that  the 
ovary  is  the  point  at  which  the 
two  germs  meet  ?  That  idea  is 
generally  embraced  by  physiolo- 
gists of  the  present  day. 

What  changes  take  place  in 
the  ovary  after  a  fecundating 
copulation  ?  One  of  the  vesi- 
cles enlarges  rapidly,  soon  rises 
above  the  surface  of  the  organ, 
absorption  of  its  peritonaeal  cov- 
ering takes  place,  and  it  is  soon 
embraced  by  the  fallopian  tube, 
and  carried  toward  the  cavity 
of  the  uterus.     Fig.  22. 

What  is  the  appearance  of  an  ovarium  after  the  ovule 
has  been  removed  ?     First,  there  is  an  eflfusion  of  blood 


Fig.  22. 


GENERATION — C£)NCEPTION.  59 

into  the  cavity,  whence  the  ovule  was  taken — then  a  yel- 
low cicatrix  called  the  corpus  luteum,  or  yellow  body. 

CONCEPTION. 

What  distinction  does  Professor  Meigs  make  be- 
tween fecundation  and  conception  ?  1.  Fecundation 
is  the  vivifying  and  vitalizing  of  a  maturated  ovum 
by  the  application  to  it  of  certain  elements  produced 
by  the  male,  no  matter  where  they  may  be  brought  in- 
to contact,  whether  in  the  ovaries,  the  fallopian  tubes 
or  the  uterus  itself. 

2.  The  term  conception  is  restricted  by  him  to  the 
"  fixation  of  a  fecundated  ovum  upon  the  living  surface 
of  the  mother." 

PREGNANCY. 

What  is  pregnancy  ?  The  retention  and  development 
of  an  embryo  or  fetus,  within  some  part  of  the  female. 

How  many  kinds  of  pregnancy  are  there  ?  Two — 
uterine  or  normal,  and  extra  uterine  or  abnormal  preg- 
nancy. 

What  is  the  character  of,  or  what  constitutes  a 
uterine  or  normal  pregnancy?  The  fact  that  the 
ovule  when  fecundated,  is  removed  from  the  ovary, 
carried  along  the  fallopian  tube  and  deposited  in  the 
cavity  of  the  uterus,  in  which  it  is  retained  and  ma- 
tured till  capable  of  living  after  parturition. 

What  would  you  consider  to  be  preternatural,  ab- 
normal, or  extra  uterine  pregnancy?  The  circum- 
stances of  the  development  of  the  fecundated  ovule  in 
the  ovarium,  the  fallopian  tube,  in  the  cavity  of  the 
peritonaeum. 

Into  how  many  varieties  is  true  uterine  pregnancy 
divided  ?  Simple  pregnancy  with  one  ovum.  Double, 
triple,  &c.  pregnancy,  when  there  are  two,  three,  or 
more  fetuses.  Complicated  pregnancy,  when  there 
exists  a  polypus,  great  quantity  of  water,  or  any  dis- 
eased state  of  the  product  of  conception,  or  of  the 
womb  itself. 


60  GENEKATION — PREGNANCY. 

What  varieties  does  extra  uterine,  irregular  or  ab- 
normal pregnancy  present?  Four  varieties,  deter- 
mined bj  the  seat  occupied  by  the  fecundated  germ. 
1st,  Ovarian  ;  2d,  Abdominal ;  3d,  Tubal;  4th,  Mixed 
or  interstitial  pregnancy. 

What  changes  take  place  in  the  genital  system,  after 
a  fecundating  copulation  ?  The  tubes  which  were 
erect  during  the  copulation,  continue  so  ;  the  uterus 
participates  in  the  general  turgescence,  and  is  pre- 
pared to  undergo  a  new  development  for  the  accommo- 
dation of  the  ovum. 

ALTERATIONS  IN  THE  CERVIX  AND  OS  UTERI. 

What  is  the  usual  size  of  the  neck  of  the  uterus  in 
the  unimpregnated  adult  female  ?  One  inch  long,  half 
inch  thick. 

What  size  does  it  acquire  during  the  first  two  months 
of  pregnancy  ?  It  is  somewhat  thicker,  and  nearly 
two  inches  long. 

How  long  does  this  development  of  the  neck  con- 
tinue after  the  commencement  of  gestation  ?  Until 
the  fourth  month. 

When  does  it  begin  to  shorten  again?  During  the  sixth. 

How  much  shorter  is  it  at  the  end  of  the  sixth 
month  ?     One-fourth. 

How  much  at  the  end  of  the  seventh  month?  One-half. 

How  much  less  at  the  end  of  the  eighth  month  ? 
Three-fourths. 

What  is  the  state  of  the  neck  at  the  end  of  the 
ninth  month  ?     Nearly  all  expanded. 

Is  this  a  rule  without  exceptions  ?  No,  it  is  true  in 
general,  but  cannot  always  be  relied  on  as  a  positive 
sign  of  the  advancement  of  pregnancy. ' 

What  minute  description  has  Dr.  Chailly,  ex-Chief 
of  the  Obstetric  Cllnique  of  the  Faculty  of  Paris,  given 
or^the  changes  which  the  uteri  undergoes  in  the  dif- 
ferent months  of  gestation  ?  In  a  work,  the  use  of 
which  was  authorized  by  the  Royal  Council  of  Public 
Instruction,  in  France,  he  says,  the  transverse  orifice 
of  the  primipara  becomes  circular  about  the  end  of  the 


GENERATION — PREGNANCY. 


61 


third  month  of  pregnancy ;  it  is  regular  in  its  contour 
and  closed,  the  os  tincse  is  smooth  and  polished  ; 
the  two  lips  are  nearly  on  the  same  line,  in  conse- 
quence of  the  shortening  of  the  anterior  lip  ;  the  entire 
neck   measures   about   two   inches,    as   is   shown   in 

Fig.  23. 


Fig.  24. 


in  which  and  all  the  following  diagrams,  intended  to  illus- 
trate this  subject,  (and  which  have  been  reduced  to  one- 
third  of  the  natural  size)  the  space  between  the  transverse 
lines  represents  the  super  vaginal 
portion  of  the  neckof  the  uterus. 

In  the  woman  who  has  had  chil- 
dren the  orifice  is  also  rounded, 
as  in  fig.  24,  but  it  is  irregular  and 
presents  a  number  of  cicatrices  es- 
pecially on  the  left.  It  is  some- 
times open,  and  will  admit  the 
extremity  of  the  finger.  The 
neck  is  much  larger  than  in  the 
primip,  it  is  also  shorter,  softer,  and  less  smooth. 

The  changes  in  the  vaginal  portion  of  the  uterus, 
after  the  end  of  the  third  month,  do  not  exhibit  such 
defined  differences  as  to  be  readily  appreciated  ;  it  is 
not  until  the  end  of  the  fifth  month  that  marked 
alterations  in  this  part  of  the  uterus  can  be  re- 
cognised. The  diagram  25,  representing  the  condition 
G 


62  GENERATION — PREGNANCY. 

Fig.  25. 


Fig.  26. 


of  the  cervix  in  a  primip,  at  the  end  of  the  fourth 
is  not  apparently  changed  from  that  at  the  end  of 
the  third  month.  The  same  may 
be  said  in  comparison  of  the 
condition  of  the  multipara  at 
an  equal  period,    rig.26. 

At  the  end  of  the  fifth 
month,  the  uterus  being  ele- 
vated above  the  superior  strait,  ^ 
the  finger,  in  seeking  the  neck, 
will  have  to  pass  higher  up 
than  at  the  previous  period. 
The  fundus  being  slightly  inclined  to  the  right 
and  in  front,  the  neck  will  of  course  be  directed  a 
little  backward  and  to  the  left:  the  neck,  in  its 
totality,  still  measures  from  fifteen  to  eighteen  lines, 
and  this  diminution  of  its  length  is  eff'ected  at  the  ex- 
pense of  its  vaginal  portion  only ;  the  portion  of  the 
neck  above  the  vagina,  having  undergone  no  diminu- 
tion, which  circumstance  can  sometimes  be  ascer- 
tained at  this  period  by  introducing  a  finger  into  the 
cul-de-sac  of  the  vagina. 

In  primiparse,  the  vaginal 
portion  has  preserved  a  cer- 
tain regularity  of  its  form :  it 
is  however  softer,  and  the  two 
lips  are  on  a  level ;  but  the 
orifice  is  still  closed.  Fig.  27. 
In  women  who  have  borne 
children,    the   neck   is    consi- 


Fig.  27. 


GENERATION — PREGNANCY. 


63 


In  women  who  have 


derably  softer  and  shorter :  the  external  orifice,  which 
is  irregular,  begins  to  open,  and  will  permit  the  intro- 
duction of  half  of  the  first  pha- 
lanx of  the  fore-finger,  and 
sometimes  more,  (see  fig.  28.) 

At    the    end    of   the    sixth 
month,  the  vaginal  portion  of 
the  uterus  continues  to  soften, 
and    diminish   in    length;  the 
orifice    also    opens   more    and 
more ;  the   first    phalanx  may 
be   introduced  in  the  os  uteri, 
(as  shown   in  fig,    29,)  of  the 
primip,  in   some  few  instances, 
borne  children,  the  finger  will 
penetrate  to  one  half  the  neck, 
as  may  be  seen  in  the  diagram ; 
it  will  occasionally  even  reach 
the  internal  orifice,  but  will  not 
pass  beyond  it,  (see  fig.  30.) 

At  the  end  of   the  seventh 
month,  the  neck  is  carried  far 

backward  and  to  the  left:  it  is  sometimes  difficult 
to  reach,  and  measures  in 
its  whole  length  from  twelve 
to  fifteen  lines.  This  di- 
mension is  effected  at  the 
expense  of  the  vaginal  por- 
tion only,  which  has  become 
larger,  and  in  primiparse 
measures  but  a  few  lines ;  (fig. 
31,)  it  is  at  this  period  almost 
completely  eff*aced  in  women  who  have  had  children, 
(as  represented  in  fig.  32.)  In  the  primip,  the  vaginal 
orifice  will  sometimes  allow  the  finger  to  penetrate  to 
one  half  of  the  neck,  w4iile  in  the  multiparous  woman 
the  finger  can  often  reach  to  the  internal  orifice, 
into  which  indeed  it  may  enter  if  the  woman  has  had 
many  children. 


Fig.  30. 


64 


GENERATION — PREGNANCY. 


the  neck  itself. 


At  the  end  of  the  eighth  month  the  vaginal  neck  is 
almost  entirely  effaced :  in  pri- 
miparae  however,  the  lips  still 
measure    a    few   lines.     It  is 
directed      considerably    back- 
ward and  to  the  left,  and  this 
circumstance  renders  it  difficult 
to  reach.    This  difficulty,  how- 
ever,  depends  more  upon  the 
anteversion  of  the  body  of  the 
uterus  than  upon  the  height  of 
In  women  who  have  borne  a  number 
of   children  the  vaginal  ori- 
fice is  so  soft  and   open  that 
it  becomes    confounded  with 
the  walls  of  the  vagina :  and 
the   orilj  certainty  that  the 
accoucheur    has  that   he  has 
reached  the  neck  is,  that  the 
finger    penetrates    an    orifice 
widely  open,  in  front  of  which 
is  nothing  more  than  the  rudiment  of  the  anterior 
lip.     This   orifice  is    found 
shaped,  and  the  finger  pene- 
trates it  deeply  in  order  to 
pass    the  internal    opening, 
which    is   more  or  less   di- 
lated, (fig.   33.)     In   primi- 
parse,  the  neck  less  soft  and 
dilated,    permits    the  finger 
to  reach  only  as  far  as  the  in- 
ternal orifice,  (fig.  34,  p.  65.) 
In  women  who  have  had  chil- 
dren, there  is  no  neck  at  the 
end    of  the    ninth    month. 
The    internal    and  external 
orifices  become   confounded 
and  are  dilated  so  as  to  allow  the  finger  to  feel  through 
the  i^nembranes  the  presenting  part  of  the  fetus,  (fig. 


GENERATION — PREGNANCY. 


65 


15.)     In  primips  the  supravaginal  portion  of  the  neck 
till   preserves    a    few   lines    in 

Fig.  34. 


Fig.  35. 


85.J 

still   preserves 

length,  which  do  not  become 
effaced  until  after  labor  has  com- 
menced, the  vaginal  portion  alone 
is  completely  obliterated  ;  a  very 
slight  thickness  of  tissues  sepa- 
rates the  two  orifices,  the  exter- 
nal is  open,  but  the  finger  cannot 
enter  the  internal,  (see  fig.  36.) 

Does  Dr.  Chailly  mean,  by  his  careful  description 
of   the    state    of  the   cervix,   to 
establish  the  fact  that  it  is  easy 
to  decide  upon  the  positive  ex- 
istence of  pregnancy  in  the  early 
months?     He  candidly  declares 
that,   it   is  not  always   easy  to 
distinguish  the  difference  in  the 
characters  presented   by  the  os 
uteri.     Certain  circumstances,  as 
painful  condition  of  the  abdomi- 
nal walls,  tumefaction  of  the  la- 
bia   majora  and    sensibility  of 
womb,  will  occasionally  render  it 
impossible  to  detect  these  signs. 
And   again,   if  in  their  absence, 
it  is  at  least,  in  a  majority  of 
cases,  possible  to  deny  the  ex- 
istence of  pregnancy,  yet  we 
cannot  always,  when  the  signs 
are  present,  positively  affirm 
that  pregnancy  exists ;  for  at 
this  period  of  gestation,  as  has 
already  been  observed,  all  that 
we    can    do  is    to     ascertain 
tliat    the  uterus    is  enlarged ; 
but  whether  this  development 
depends   on   the  presence   of 
a  fetus  or  upon  an  abnormal 
6* 


66  GENERATION — PREGNANCY. 

condition  is  a  point  possible  it  is  true  to  establish  in 
some  instances;  while  in  others  the  whole  matter  rests 
in  doubt  until  additional  symptoms  render  the  diag- 
nosis positive. 

In  fact,  at  the  approach  of  the  menstrual  period  of 
some  women,  the  uterus  in  consequence  of  its  con- 
gested condition,  occasionally  becomes  as  large  as  in 
the  third  month  of  pregnancy,  and  we  are  never  liable 
to  error,  because  in  this  case  the  neck  is  slightly 
softened  and  open.  At  other  times  the  menses 
retained  in  the  cavity  of  the  uterus,  in  consequence 
of  the  closing  of  its  internal  orifice,  distend,  by  their 
accumulation,  the  walls  of  this  organ,  -and  thus  give 
rise,  sympathetically,  to  many  of  the  presumptive 
signs,  such  as  tumefaction  and  pain  in  the  breasts, 
disturbance  in  the  digestive  functions,  &c.,  &c.,  cir- 
cumstances which  increase  the  chances  of  error. 

RANGES  IN  THE  FORM  OF  THE  UTERUS. 

What  change  takes  place  in  the  form  of  the  uterus  ? 
It  becomes  more  regularly  pyriform,  and  even  ovi- 
form. 

What  portions  then  become  most  rapidly  developed  ? 
The  anterior  and  posterior  surfaces. 

Which  of  these  two  surfaces  developes  the  most  ra- 
pidly ?     The  posterior. 

At  what  period  of  pregnancy  does  the  body  of  the 
uterus  become  completely  spherical  ?  At  the  end  of 
the  fifth  month. 

Has  the  neck  begun  to  shorten  at  this  time  ?  Yes, 
slightly ;  it  is  mammillated,  being  like  a  nipple  on  a 
mamma. 

What  is  the  original  position  of  the  uterus  in  its 
non-gravid  state  ?  It  is  situated  in  the  axis  of  the  su- 
perior strait,  with  its  fundus  just  above  the  brim  of 
the  pelvis. 

Does  it  descend  a  little  during  the  first  and  second 
months  ?  Yes — but  chiefly  because  of  its  develop- 
ment. 


GENERATION — PREGNANCY.  67 

Does  it  continue  to  bear  the  same  relation  with  the 
axis  of  the  pelvis  as  it  is  precipitated  ?     It  does. 

Does  this  precipitation  ever  extend  as  far  as  to  the 
vulva  ?     Yes,  in  some  rare  cases. 

Does  its  orifice  then  point  forwards  ?  It  points  for- 
wards in  the  direction  of  the  axis  of  the  vagina. 

Where  is  the  fundus  usually  found  at  the  third 
month  of  pregnancy  ?  A  little  above  the  margin  of 
the  superior  strait. 

What  is  the  situation  of  the  uterus  at  the  end  of 
the  fourth  month  ?  A  large  portion  of  it  is  out  of  the 
cavity  of  the  pelvis. 

How  high  is  the  top  of  the  fundus  at  the  end  of  the 
fifth  month  ?  Generally  half  way  between  the  pubes 
and  umbilicus  of  the  mother. 

IIow  high  at  the  end  of  the  sixth  month?  On  a 
level  with  the  umbilicus. 

How  high  at  the  end  of  seven  months?  Two  or 
three  fingers'  breadth  above  the  umbilicus. 

How  high  at  the  end  of  the  eighth  month  ?  It  has 
reached  the  epigastric  region. 

Where  is  the  fundus  at  the  end  of  the  ninth  month  ? 
Usually  rather  lower  than  at  the  end  of  the  eighth,  in 
consequence  of  the  rapid  anterior  development  of  the 
organ. 

What  relation  does  the  gravid  uterus  hold  with  the 
intestines  ?  It  carries  them  upwards  and  backwards, 
being  itself  in  contact  with  the  parieties  of  the  ab- 
domen. 

What  are  the  dimensions  of  the  uterus  at  the  full 
period  of  utero-gestation  ?  Twelve  to  fourteen  inches 
from  fundus  to  orifice,  nine  to  ten  in  the  widest  part, 
and  eight  to  nine  antero-posteriorly. 

Is  the  axis  of  the  uterus  liable  to  be  modified  by 
the  pressure  of  the  abdominal  muscles  ?  It  is  so,  par- 
ticularly in  first  pregnancies. 

Does  the  tension  of  these  muscles  in  a  first  preg- 
nancy usually  retain  the  axis  of  the  uterus  more  nearly 
parallel  with  the  axis  of  the  body  ?     Yes. 


68  GENERATION — PREGNANCY. 

What  other  circumstances  or  causes,  modify  the  di- 
rection of  the  axis  of  the  uterus  during  gestation  ?  The 
uterine  ligaments,  abdominal  viscera,  and  spinal 
column. 

Is  the  orifice  of  the  uterus  always  directed  to  the 
portion  of  the  pelvis  opposite  to  that  towards  which 
the  fundus  presents?  It  is  mostly  nearly  so,  though 
sometimes  it  is  rather  posterior  to  this  right  line,  and 
sometimes  it  appears  to  be  retained  upwards  and  back- 
wards, in  consequence  of  the  want  of  development  of 
the  fibres  of  the  posterior  part  of  the  cervix. 

Is  the  orifice  of  the  uterus  sometimes  thrown  so  far 
back  into  the  hollow,  or  above  the  promontory  of  the 
sacrum,  in  cases  of  anterior  obliquity  as  to  be  out  of 
reach  of  the  finger  ?  When  there  is  anterior  obliquity 
it  is  always  so. 

Are  the  walls  of  the  gravid  uterus  thicker  than 
when  in  the  unimpregnated  state  ?  Very  slightly 
thicker. 

What  changes  does  the  uterine  parenchyma  pass 
through  in  this  development  ?  It  becomes  softer,  the 
muscular  fibres  are  developed,  the  nerves,  blood  ves- 
sels, and  lymphatics  all  increase  in  size. 

By  how  many  times  are  the  blood-vessels  enlarged  ? 
Arteries  four  times,  and  the  veins  even  more  than  this. 

What  is  meant  by  what  are  called  venous  sinuses  ? 
Enlargements  and  duplications  of  the  veins  merely, 
whose  orifices  are  patulous  upon  the  internal  surfaces 
of  the  gravid  uterus. 

Is  the  sensibility  or  irritability  of  the  uterus  increased 
with  gestation  ?  It  is  so,  and  this  is  important  to  be 
borne  in  mind  in  the  management  of  pregnant  women. 

ALTERATIONS  OF    SIZE    AND   POSITION  OF    THE    PELVIC 
AND  ABDOMINAL  VISCERA  CAUSED  BY  PREGNANCY. 

Does  the  embryo  enlarge  the  uterus  by  the  irrita- 
tion of  its  presence  ?  It  probably  does,  not  however 
so  much  by  mechanical  distension,  as  by  exciting  the 
vital  process  of  development,  a  result   of  irritation  or 


GENERATION — PREGNANCY.  69 

excitement  caused  by  fecundation ;  as  the  ovum  en- 
larges it  keeps  up  the  excitement  within  the  uterus. 

If  the  ovum  be  accidentally  ruptured  and  discharged, 
is  not  the  development  of  the  uterus  arrested  ?  It  is 
pirobably  in  all  cases. 

How  is  the  vagina  affected  during  the  process  of 
uterine  developement  ?  It  becomes  rather  shorter 
during  at  least  two  months  ;  and  from  the  fourth 
month  it  becomes  longer  and  larger. 

How  is  the  peritonaeum,  which  is  spread  over  the 
uterus  and  its  appendages,  enlarged  during  gestation  ? 
By  development!  and  not  mere  stretching. 

Do  the  fallopian  tubes  and  ovaries  remain  vascular 
after  conception  ?     They  do  for  some  time. 

How  are  they  situated  in  reference  to  the  uterus  at 
the  end  of  pregnancy  ?  They  hang  alongside  of  this 
organ  in  the  folds  of  the  peritonoeum. 

Do  the  round  ligaments  assume  a  muscular  character  ? 
They  do — Velpeau  says  he  has  seen  them  contract 
during  labor,  and  they  often  draw  the  uterus  forward 
during  pregnancy. 

What  effect  has  advanced  pregnancy  upon  the  uri- 
nary bladder  ?  It  is  mostly  carried  upwards  and  for- 
wards as  the  uterus  enlarges. 

What  effect  has  this  upon  the  situation  of  the 
urethra  ?     It  then  becomes  nearly  perpendicular. 

Where  may  you  expect  to  find  the  meatus  in  this 
case  ?     Drawn  a  little  back  from  its  usual  situation. 

How  would  you  introduce  the  female  catheter  under 
these  circumstances  ?  By  depressing  the  handle  and 
carrying  the  point  under  the  sub-pubic  ligament. 

Is  the  straight  catheter  always  sufficient  to  pass  in- 
to the  cavity  of  the  bladder  ?  It  is  sometimes  better 
to  use  the  curved  or  male  catheter,  in  consequence  of 
the  direction  which  the  cavity  is  forced  to  take  by  the 
pressure  of  the  uterus. 

What  effect  does  the  pressure  of  the  gravid  uterus 
Bometimes  exert  on  the  functions  of  the  pelvic  viscera  ? 


70  GENERATION — PREGNANCY. 

It  often  causes  obstructions  to  the  natural  functions  of 
the  bowels  as  well  as  bladder. 

Is  the  rectum  sometimes  more  free  after  the  fourth 
month  ?  Yes — but  very  frequently  it  is  beyond  the 
influence  of  the  abdominal  muscles,  and  hence  is  often 
the  seat  of  great  fecal  accumulations. 

In  what  manner  are  the  respiratory  organs  affected 
during  the  latter  months  of  pregnancy  ?  During  the 
eighth  and  part  of  the  ninth  month,  the  fundus  of  the 
uterus  presses  the  diaphragm,  liver,  &c.  upwards,  and 
thus  shortens  the  vertical  diameter  of  the  chest  and 
expands  its  base. 

What  effect  is  sometimes  produced  by  the  distension 
of  the  skin  of  the  abdomen  ?  Sometimes  its  texture 
is  modified,  leaving  resemblances  to  cicatrices. 

Is  the  liability  to  crural  hernia  diminished  as  preg- 
nancy advances  ?  Yes,  because  the  intestines  are  car- 
ried up  above  the  abdominal  rings,  and  their  place  is 
occupied  by  the  uterus. 

Is  the  woman  more  subject  to  umbilical  hernia  ? 
Yes. 

At  what  period  of  pregnancy  does  the  navel  pout 
out  ?     About  the  fifth  and  sixth  months. 

Why  does  it  flatten  again  after  this  ?  Because  the 
fundus  of  the  uterus  rises  above  it. 

Why  are  women  during  pregnancy  particularly  dis- 
posed to  varicose  veins,  and  to  edema  or  anasarca  ? 
Because  of  pressure  upon  the  vena  cava  and  absor- 
bents. 

Does  this  varicose  state  of  the  limbs  sometimes  con- 
tinue after  delivery  ?  Yes — and  is  then  increased  at 
every  subsequent  pregnancy. 

While  all  these  changes  are  going  on  externally, 
what  is  taking  place  in  the  cavity  of  the  uterus  ?  Its 
lining  membrane  becomes  more  developed,  more  villous 
and  vascular. 


GENERATION — PREGNANCY.  Tl 

DECIDUAL  MEMBRANE  OF  THE  UTERUS. 

What  is  secreted  by  the  lining  of  the  uterus  ?  A 
layer  of  coagulable  lymph,  gelatinous  in  character, 
which  speedily  becomes  organized,  vascular,  and  red- 
dish. 

What  is  this  membrane  called  ?  Decidua  or  ca- 
duca. 

How  long  does  it  remain  next  the  uterus  ?  During 
pregnancy. 

When  and  how  is  it  disengaged  ?  At  the  time  of 
parturition,  when  it  is  thrown  off  by  uterine  contrac- 
tions at  the  same  time  with  the  placenta,  or  shortly 
after  in  small  pieces  with  the  lochia. 

How  low  down  the  cavity  of  the  uterus  does  this 
lining  extend  ?     To  the  internal  os  uteri. 

What  is  the  character  of  its  external  surface?  Vil- 
lous or  shaggy. 

What  does  Velpeau  call  this  membrane  ?  Anhistous, 
and  considers  it  unorganized. 

What  are  the  proofs  of  its  organization  ?  Its  vas- 
cularity ;  it  was  injected  by  Ruysch,  Burns,  &c.  The 
decidua  of  a  cat  has  been  injected  by  Drs.  Goddard 
and  Betton. 

Is  its  growth  or  development  another  proof  of  its 
organization?  Yes — it  is  also  subject  to  diseases,  and 
it  becomes  very  thin  towards  the  last,  like  serous  or  cel- 
lular tissue.  A,  the  decidua  reflexa,  with  a  few  of  the 
smooth  orifices  of  the  canals  passing  between  the  cells  of 
the  chorion  and  decidual  cavity — natural  size.  The 
opening  had  almost  entirely  closed  in  that  part  of  the 
decidua  reflexa  which  was  most  remote  from  the  pla- 
centa, and  the  villi  of  the  chorion  had  here  also  dis- 
appeared. B,  the  openings  in  the  decidua  reflexa,  as 
seen  through  a  simple  lens  of  an  inch  focus.  C,  the 
inner  surface  of  a  small  portion  of  the  uterine  deci- 
dua or  decidua  vera,  unusually  thick  and  rugous.  D, 
a  magnified  view  of  the  same  membrane,  witli  a  few 
small  orifices  of  vessels.     Fig.  37,  p.  72. 


72 


GENERATION — DECIDUA. 


Fig.  37. 


In  figure  38   are  represented  the  openings   in  the 
decidua  reflexa  and  uterine  decidua,  as  seen  in  another 

Fig.  38. 


GENERATION— DECIDUA. 


78^ 


ovum  of  an  earlier  age.  A,  a  small  portion  of  deci- 
dua  reflexa  magnified.  B,  inner  surface  of  uterine 
decidua,  with  the  veins  passing  obliquely  through  the 
membrane  to  the  uterine  surface. 

In  fig.  39,  the  orifices  of  the  veins  of  the  uterine 
decidua  opening  into  the  decidual  cavity :  natural 
size. 


Fig.  39. 


^^^ 


In  fig.  40,  a  portion  of  the  same  membrane,  as  seen 
through  a  good  lens. 


Fig.  40. 


Is  it  a  complete  lining  to  the  uterus  ?     It  lines  the 
whole  cavity  of  the  body  of  the  uterus,  and  by  many 

7 


74 


GENERATION — DECIDUA. 


Fig.  41. 


Fig.  42. 


physiologists  it  is  believed 
that  it  covers  the  orifice 
of  the  tubes  and  the  inter- 
nal OS  uteri,  (fig.  41.) 

What  is  the  use  of  this 
decidua  ?  It  forms  the  me- 
dium of  contact  between 
the  uterus  and  the  ovum. 

After  how  many  days 
from  fecundation  does  it 
line  the  cavity  ?  Probably 
four,  five,  or  six. 

As  the  ovum  cannot  fall 
into  the  cavity  of  the  ute- 
rus at  its  first  approach  to 
it,  in  what  manner  is  it  ac- 
commodated upon  its  arri- 
val at  the  end  of  the  fallo- 
pian tube  ?  As  it  becomes 
developed  it  adheres  to,  and 
causes  a  growth  of,  that  part 
of  the  membrana  decidua, 
which  is  in  contact  with  that 
angle  of  the  uterus. 

Does  this  action  give  rise 
to  the  apparent  formation  of 
two  membranes  ?  It  has  that 
efi"ect,  (fig.  42.) 

DECIDUA  UTERI  AND  DECIDUA  REFLEXA. 

What  names  have  been  given  to  these  ?  That  with 
which  the  ovum  is  in  contact,  is  called  the  decidua 
reflexa,  or  decidua  ovi ;  and  that  which  is  next  the 
uterus,  the  decidua  vera,  or  decidua  uteri. 

Does  this  arrangement  correspond  with  that  of  tho 
pleura  pulmonalis,  and  the  pleura  costalis  ?  It  does, 
I'or  like  the  lungs,  the  ovule  is  thus  really  exterior  to 
the  sack  of  decidua,  though  apparently  enclosed  by  it. 

Are  the  two  layers  of  the  decidua,  viz. :  decidua  re- 


GENERATION — OVUM.  ?S 

flexa,  and  decidua  vera  at  once  in  close  contact  with 
each  other  ?  No,  one  is  closely  attached  to  the 
ovum,  while  the  other  is  loose  around  it. 

What  is  interposed  between  the  two  layers  ?  The 
interspace  is  filled  with  fluid. 

At  about  what  period  of  pregnancy  do  these  two 
layers  come  in  contact  ?     About  the  fourth  month. 

CONSTITUTION  OF  THE  OVUM. 

What  is  the  arrangement  of  the  ovule  in  reference 
to  its  investments  ?  It  has  two  membranes ;  the 
chorion  externally,  and  the  amnion  internally,  sur- 
rounding it. 

Are  these  membranes  endowed  with  vitality  ?  They 
are. 

What  does  the  inner  membrane  contain  ?  A  fluid 
in  which  is  suspended  a  corpuscle,  or  cicatricula. 

What  is  the  probable  size  of  the  ovum  at  the  time 
of  its  entrance  into  the  uterus  from  the  fallopian 
tube  ?  It  is  supposed  to  be  about  the  size  of  a  hemp 
seed. 

What  length  of  time  does  it  probably  require  for  the 
ovule  to  pass  along  the  tube  from  the  ovary  to  the 
uterus  ?     A  week,  or  a  little  more. 

Does  any  portion  of  the  shaggy  surface  of  the 
chorion  come  in  contact  with  the  uterus  ?  No,  for 
the  two  layers  of  the  caduca  or  decidua  are  inter- 
posed. 

How,  then,  does  the  ovum  derive  its  support  from 
the  uterus  ?  The  decidua  receives  the  blood  from  the 
uterus,  and  transmits  it  to  the  ovum  through  the 
shaggy  surface  or  the  radicles  of  the  chorion. 

What  are  the  anatomical  characters  of  the  chorion  ? 
It  is  a  serous  or  white  membrane,  and  does  not  carry 
red  blood ;  its  internal  surface  is  smooth,  but  exter- 
nally it  is  villous  or  shaggy ;  its  little  flocculi  being 
like  so  many  radicles. 

Are  these  radicles  vessels?  Some  physiologists 
consider   that   they  are  vascular,  and   others  regard 


70  GENERATION — OVUM. 

them  as  areolar  spongioles,  and  not  permeable  con- 
duits. 

Does  the  chorion  increase  in  thickness  and  strength 
as  it  becomes  developed  ?  It  is  believed  that  it 
does  at  the  same  time  that  the  decidua  becomes 
thinner. 

Poes  the  chorion  form  the  basis  of  the  placenta  ? 
This  point  is  not  well  settled,  though  in  the  opinion 
of  Rigb}^  Hodge,  Dewees,  and  some  others,  it  does. 

What  are  the  characteristics  of  the  amnion  ?  It 
is  a  delicate  small  sac  situated  within  the  chorion. 

Is  it  different  in  any  respect  from  the  chorion  ? 
Yes  ;  it  is  smooth  and  transparent,  though  it  is  slightly 
adherent  in  places  to  the  chorion  by  means  of  mu- 
cous filaments  or  lamellae  which  covers  its  outer  sur- 
face. 

What  fluid  does  it  enclose  ?     The  liquor  amnii." 

Is  the  amnion  originally  in  contact  with  the  chorion 
throughout  ?  No ;  originally  it  is  smaller  than  the 
chorion. 

What  is  interposed  between  the  two  membranes  ? 
A  kind  of  vitriform  substance,  enclosed  in  a  delicate  re- 
ticulated sac. 

At  about  what  period  of  gestation  does  the  amnion 
come  in  contact  with  the  chorion  ?  After  the  second 
month ;  though  agreeably  to  Velpeau  there  is  much 
difference  in  different  individuals,  in  this  respect.  In 
some  cases,  it  is  known  to  have  a  considerable  amount 
of  fluid  between  it  and  the  amnion  at  the  full  term  of 
gestation,  the  escape  of  which  has  led  to  the  idea 
that  the  liquor  amnii  had  passed  off. 

Is  the  amnion  a  stronger  membrane  than  the  cho- 
rion ?     It  is  usually  much  stronger. 

What  is  the  character  of  the  liquor  amnii  ?  It  is 
peculiar ;  unctuous,  and  rather  more  consistent  than 
pure  water ;  has  also  rather  greater  specific  gravity. 

What  circumstances  may  modify  its  color  and  odor  ? 
The  excretions  from  the  fetus. 

What  is  the  relative  quantity  of  the  fluid  during  the 


GENERATION—OVUM.  77 

whole  period  of  gestation  ?  At  first  it  forms  but  a 
thin  stratum,  but  it  increases  rapidly  till  the  second 
month.  At  three  months  it  weighs  more  than  the 
fetus.  After  this  period  the  quantity  of  the  fluid  rel- 
atively diminishes. 

What  is  the  quantity  usually  present  at  birth  of  the 
fetus  ?  A  pint ;  sometimes  quarts,  and  in  a  few  rare 
cases  even  gallons. 

Does  this  increased  quantity  appear  to  exert  any 
influence  on  the  health  of  the  child  ?  It  usually  pro- 
duces no  manifest  effect. 

What  appear  to  be  the  uses  of  this  fluid  ?  Although 
its  intrinsic  use  is  not  known,  it  is  evidently  adapted 
to  allow  space  and  facilities  for  motion,  development, 
&c.,  of  the  fetus. 

May  the  presence  and  increase  of  the  liquor  amnii 
be  regarded  as  a  concentric  stimulus  to  the  develop- 
ment of  the  uterus,?  This  opinion  is  entertained  by 
some  highly  respectable  authority. 

Is  the  liquor  amnii  subject  to  any  changes  in  color 
and  quality  ?  It  is  modified  in  this  respect  by  various 
causes ;  as  diseases,  &c. 

What  does  Velpeau  suppose  to  be  located  between 
the  amnion  and  chorion,  until  they  are  approximated 
by  the  developement  of  the  amnion  ?  The  reticulated 
tissue,  containing  a  sort  of  vitreous  humor.  He  calls 
it  the  reticulated  body,  which  after  the  chorion  and 
amnion  come  together,  corresponds  to  the  allantois  of 
inferior  animals. 

What  is  Muller's  description  and  magnified  drawing 
of  an  ovum  which  he  supposed  to  be  about  twenty-eight 
days  old?  A,  fig.  43,  the  natural  size.  B,fig.  44,  the  mag- 
nified view.  C,  fig.  45,  a  view  still  more  highly  magnified, 
with  the  membranes  restored,  and  references  to  the  sev- 
eral parts,  a,  a,  chorion  laid  open  and  reflected ;  5,  5,  5, 
albuminous  space  betwixt  the  amnion  and  chorion  ;  c, 
amnion  ;  d,  umbilical  vesicle  ;  d\  pedicle  of  the  um- 
bilical vesicle ;  e,  noose  of  intestine  communicating 
with  d^ ;  ^,  heart ;  A,  lower  jaw ;  i,  ear ;  k,  cerebel- 


GENERATION — EMBRYO. 


lum ;  h^^  hemispheres ;  P,  corpora  quadrigemina  ;  Z, 
anterior,  and,  m,  posterior  extremity ;  n^  point  where 


Fig.  43. 


Fig.  44. 


Fig.  45. 


GENERATION— EMBRYO.  79 

the  allantois  and  chorion  have  coalesced  ;  n\  umbilical 
cord  ;  p,  liver  ;  r,  eye ;  1,  2,  3,  branchial  fissures. 

How  does  Professor  Meigs  describe  the  allantois  ? 
*'  This  is  a  small  vesicle  or  bladder,  which  rises  from 
the  pelvic  extremity  of  the  embryo,  and  springing  for- 
wardg  from  the  still  open  belly  proceeds  to  place  itself 
betwixt  the  outer  chorion  and  the  inner  amnion,  en- 
larging itself  and  at  length  attaching  itself  to  the 
chorion,  carrying  with  it  the  blood-vessels  which  create 
it,  and  which  are  umbilical  arteries  which  it  applies  by 
their  distal  extremities  to  the  inner  aspect  of  the 
chorion.  This  chorion  they  pierce  and  go  through  to 
seek  an  attachment  as  placental  tufts,  on  the  inner 
wall  of  the  womb.  This  bladder  is  the  allantois. 
When  the  belly  of  the  embryo  becomes  closed  in,  this 
bladder  becomes  strictured  at  the  navel,  and  in  the 
tractus  of  the  umbilical  cord.  The  narrow  strictured 
part  of  the  vesicle  is  now  a  long  cylindrical  tube.  The 
part  retained  within  the  now  closed  abdomen  is  the 
bladder  of  urine ;  the  long  cylindrical  part  is  the  ura- 
chus,  and  the  outer  expanded,  or  to  speak  correctly, 
uncompressed  and  unstrictured  portion  is  the  allan- 
tois." 

What  is  his  opinion  of  the  uses  of  the  allantois  or 
sausage-shaped  vesicle  ?  "  The  urine  secreted  in  the 
kidney  passes  by  the  ureters  into  the  bladder  of  urine, 
and  in  the  early  stages  of  uterine  life  flows  through 
the  urachus  into  the  bag  of  the  allantois." 

What  is  the  vesicula  alba  or  umbilical  vesicle  ? 
Dr.  Meigs,  who  has  given  a  more  full  account  than  any 
other  American  writer,  of  what  is  known  of  the 
changes  of  the  ovum  early  after  impregnation,  after 
reminding  his  reader  that  the  human  yelk  is  micro- 
scopic globule  filled  with  vitellary  corpuscles,  says, 
*'  When  the  blastoderm  has  partly  undergone  the 
morphological  changes  that  convert  it  into  the 
earliest  rudiraental  embryon,  part  of  the  yelk  cor- 
puscles still  remain  unappropriated  ;  and  as  they  are 
still  contained  in  their  original  vitelline  membrane,  they 


80 


GENERATION — EMBRYO. 


Fig.  46. 


Fig.  47. 


constitute  a  small  but  visible  "ball, 
called  the  umbilical  vesicle."     He 
illustrates  this  statement  by  the  ac- 
companying diagrams.  Originally 
the    vitellus    was    a   sphere,    of 
which  fig.  46   represents  *  seg- 
ment.     The  blastoderm  is  devel- 
oped upon  a  segment  of  this  sphere 
as  in   fig.  47.     When    the  blas- 
toderm doubles  or  folds  its  edges 
inwards  it  pinches  a  portion  of  the  vitellary  ball  as 
in  fig.  48.     In  a  still  farther 
progress  as  may  be  shown  by 
fig.  49,  the  portion  of  the  vitel- 
lary ball  that  remains  outside 
of  the    embryon  is    connected 
with  the  embryo  by  a  delicate 
tube  or  vitellary  duct." 

Into  what  portion  of  the  intes- 
tines does  it  open?  Velpeau  says 
it  comes  from  the  ileum  ;  Oker, 
Rigby  and  Ludlow  consider 
the   appendicula   vermifor- 
mis  as  the  remains  of  it. 

Is  it  situated  between 
the  chorion  and  amnion  ? 
Some  teachers  think  it  is 
outside  of  the  chorion.  Vel- 
peau says  it  is  between  the 
chorion  and  amnion. 

Fig.  49.      


GENERATION — EMBRYO. 


81 


How  is  it  composed  ?  It  consists  of  two,  perhaps 
of  three  membranous  layers. 

What  appears  to  be  its  use  ?  To  supply  the  embryo 
with  nutriment  during  the  early  periods  of  its  develop- 
ment, and  until  the  placental  circulation  is  established. 

At  what  time  does  it  totally  disappear  ?  By  the 
end  of  the  third  or  fourth  month  of  gestation. 

Are  there  any  blood-vessels  distributed  through  it  ? 
Yes  ;  both  arterial  and  venous. 

What  are  these  called  ?  Yitello-mesenteric,  or  om- 
phalo-mesenteric  vessels. 

How  does  Professor  Meigs  describe  and  illustrate 

Fig.  50. 


the  omphalo-mesenteric  vessels  and  cord  ?  "  In  per- 
fect ova,  averted  at  the  period  of  two  months,  or  a 
little  later,  the  student  will  readily  distinguish  the  um- 


82  GENERATION — PLACENTA. 

bilical  vesicle  shining  through  the  chorion  and  lying 
betwixt  it  and  the  delicate  amniotic  membrane.  I  add 
here  a  figure  that  may  serve  to  explain  its  arrangement. 
Let  a,  a,  fig.  50,  be  a  portion  of  the  abdomen  and  the 
embryo,  and  c,  c,  the  navel  or  umbilical  ring  ;  5,  5,  the 
navel  string  or  cord  laid  open ;  d,  the  umbilical  vein 
bringing  back  the  blood  from  the  placenta  and  passing 
into  the  belly  at  the  ring  to  go  to  the  liver ;  e,  /,  the 
two  umbilical  arteries  of  the  fetus  ;  A,  the  umbilical 
vesicle  or  vitelline  sac,  whose  pipe  conduit  or  efferent- 
duct  runs  along  the  umbilical  cord  to  the  navel,  and 
passing  into  the  belly  empties  itself  in  the  ileum ;  g^  g, 
Avhich  bends  up  to  receive  the  discharge ;  k,  I,  repre- 
sents the  omphalo-mesenteric  vessels." 

By  what  means  is  the  embryo  connected  with  the 
membranes  ?     By  the  umbilical  cord. 

What  is  the  composition  of  this  cord  ?  It  consists 
of  two  arteries  and  one  vein,  of  a  layer  of  amnion, 
and  perhaps  also  chorion,  with  some  albuminous  or 
gelatinous  matter  interposed. 

Whence  do  these  vessels  originate,  and  in  what  do 
they  terminate  ?  The  arteries  are  continuations  of  the 
primitive  iliacs,  while  the  vein  goes  to  pass  under  the 
edge  of  the  liver  and  enter  the  cava.  They  terminate 
in  a  great  number  of  branches  at  the  circumference 
of  the  ovum,  upon  a  portion  of  the  chorion. 

PLACENTA. 

What  is  this  congeries  of  vascular  radicles  called  ? 
Placenta. 

What  is  the  usual  size  of  the  placenta  at  the  full 
period  of  utero  gestation  ?  Its  diameter  is  from  six 
to  eight  inches ;  its  circumference,  from  eighteen  to 
twenty-four  inches  ;  and  its  thickness  from  a  few  lines 
at  the  circumference  to  an  inch  or  two  in  its  centre. 

What  is  the  character  of  its  inner  or  fetal  surface  ? 
It  is  smooth,  lined  with  the  amnion,  through  which 
the  larger  vessels  of  the  placenta  can  be  felt  and 
seen.     Fig.  51. 


GENERATION — PLACENTA. 
Fig.  51. 


What  arrangement  exists  on  its  external  or  uterine 
surface  ?  It  is  arranged  in  convolutions  or  sulci, 
which  are  distributed  in  masses,  sometimes  called  pla- 
centules.     Fig.  52. 

Fig.  52. 


Is  there  any  membrane  thrown  across  the  uterine 
surface  of  the  placenta?  The  decidua  is  believed  by 
many  physiologists  to  extend  over  its  whole  surface. 

Can  the  amnion  be  removed  from  the  inner  surface 
of  the  placenta  ?  It  can  be  readily  peeled  off  from 
the  inner  surface. 


84  GENERATION — PLACENTA. 

Is  the  chorion  more  firmly  attached  to  it?  It  is 
almost  inseparably  so. 

What  is  the  mode  of  communication  between  the 
embryo  and  uterus  during  the  first  week  of  its  uterine 
existence  ?  Through  the  membranes  entirely.  The 
decidua  receives  blood  from  the  uterus,  transmits  the 
elements  of  nutrition,  through  the  fetal  membranes  to 
the  embryo. 

What  is  Professor  Hodge's  theory  of  the  mode  of 
formation  of  the  placenta  ?  "  The  shaggy  surface 
of  the  chorion  enlarges  at  the  point  at  which  the 
ovule  happens  to  come  in  contact  with  it,  and  at 
that  point  the  placenta  is  formed,  chiefly  out  of  the 
shaggy  surface  of  the  chorion,  and  also  of  the  decidua, 
which  may  be  regarded  as  the  uterine  portion  of  the 
placenta." 

What  is  the  composition  of  the  placenta  ?  Its 
tissue  is  peculiar ;  it  is  somewhat  cellular,  but  is  made 
up  chiefly  of  ramifications  of  the  cord. 

Is  this  susceptible  of  proof  by  injection  ?  The  tis- 
sue of  the  placenta  may  be  distended  by  injecting  the 
arteries,  and  when  these  vessels  are  filled,  the  fluid 
passes  out  by  the  vein. 

Is  it  proper  to  consider  the  placenta  as  composed 
of  two  parts,  the  fetal,  and  the  uterine  portions  ?  It 
will  admit  of  that  mode  of  demonstration,  particularly 
during  the  early  part  of  pregnancy. 

What  are  these  two  portions  ?  One,  the  fetal,  is 
composed  of  the  chorion,  and  the  other,  the  uterine, 
is  derived  from  the  decidua. 

Can  these  portions  be  readily  separated  from  each 
other  ?  The  process  can  be  eff'ected  by  maceration,  as 
late  as  the  second  month  of  pregnancy. 

Do  any  large  blood  vessels  pass  from  the  uterus  into 
the  placenta  ?  No  :  the  communication  between  the 
uterus  and  the  decidua,  is  by  capillary  veins  and  arte- 
ries only. 

What  are  the  proofs  of  this  ?    The  decidua  may  be 


GENERATION — PLACENTA.  85 

injected   from  the  uterus  during  the  early  periods  of 
pregnancy. 

How  many  kinds  of  circulation  are  carried  on  in 
the  placenta  ?  Two ;  one  through  the  very  minute 
utero-placental  vessels  for  the  purpose  of  sustaining 
the  vitality  and  nutrition  of  the  placenta ;  the  minute 
vessels  extending  from  the  substance  of  the  uterus 
into  the  placenta;  and  the  other,  a  large  circulation, 
through  the  vessels  of  which  the  placenta  is  chiefly 
composed  ;  the  blood  coming  from  and  returning  to 
the  fetus,  in  a  manner  analogous  to  that  in  which  a 
small  supply  of  blood  is  sent  to  the  substance  of  the 
lungs  for  their  nutrition,  while  the  whole  mass  which 
is  to  be  sent  over  the  body,  is  passed  through  the 
great  vessels  of  the  lungs,  during  extra^  uterine  life. 

What  becomes  of  the  blood  of  the  fetus,  after  it 
has  been  carried  out  through  the  umbilical  arteries  ? 
It  returns  to  the  fetus  through  the  umbilical  vein. 

Do  the  uterine  veins  increase  in  size  as  they  ap- 
proach the  placenta  ?  They  usually  increase  very 
greatly. 

Do  they  open  directly  into  the  placenta  ?  No ; 
they  open  upon  the  decidua  by  patulous  orifices — this 
membrane  therefore  acts  like  a  valve  over  them,  to 
prevent  the  blood  from  escaping  into  the  cavity  of  the 
gravid  uterus. 

"What  is  the  proof  of  the  arrangement  ?  The  fact 
that  if  the  placenta  be  separated  before  the  uterus 
contracts,  more  or  less  venous  hemorrhage  occurs  as  a 
consequence. 

What  were  Lee's  observations  in  reference  to  this 
vascular  arrangement  ?  "  If  air  be  forcibly  thrown 
into  either  the  spermatic  arteries  or  veins,  the  whole 
inner  membrane  of  the  uterus  is  raised  by  it ;  but 
none  of  the  air  passes  across  the  deciduous  membrane 
into  the  placenta,  nor  does  it  escape  from  the  semilu- 
nar openings  in  the  inner  membrane  of  the  uterus, 
until  the  attachment  of  the  deciduous  membrane  to  the 
uterus  is  destroyed.  There  are  no  openings  in  the 
8 


86  GENERATION — PLACENTA. 

deciduous  membrane  corresponding  with  the  valvular 
apertures  in  the  internal  membrane  of  the  uterus." 

Upon  which  individual,  mother  or  child,  does  the 
placenta  depend  for  its  organic  vitality?  Upon  the 
mother. 

What  proofs  have  we  of  this  ?  First,  the  fact  that 
if  the  placenta  be  separated  from  the  uterus,  it  be- 
comes atrophied.  Secondly,  the  placenta  may  be- 
come diseased ;  it  may  become  inflamed,  and  subse- 
quently adherent  to  the  uterus.  Thirdly,  the  pla- 
centa may  sometimes  be  kept  alive  after  the  death  of 
the  fetus. 

To  what  changes  is  it  mostly  subjected  under  such 
circumstances  ?  It  generally  becomes  carneous  and 
somewhat  shrivelled,  in  consequence  of  the  failure  of 
the  fetal  circulation  through  it. 

Is  the  placenta  very  easily  separated  from  the  in- 
ternal surface  of  the  uterus  when  it  is  in  a  healthy 
state  ?  It  is — by  passing  up  the  fingers  between  the 
uterus  and  placenta,  it  may  be  very  easily  separated. 
Slight  jars,  shocks,  and  any  thing  which  excites  ute- 
rine contraction,  may  be  a  means  of  causing  a  sepa- 
ration of  the  placenta,  and  giving  rise  to  uterine  hem- 
orrhage. 

To  what  part  of  the  uterus  is  the  placenta  mostly 
attached?  According  to  the  experience  of  some^ 
mostly  to  one  of  the  sides  of  the  uterus. 

Are  there  any  nerves  in  the  placenta  ?  None  have 
yet  been  satisfactorily  discovered. 

Is  this  mass  supplied  with  lymphatics  ?  It  is  be- 
lieved by  many  that  they  exist  in  this  body  in  consid- 
erable amount. 

What  is  the  length  of  the  cord  at  the  end  of  the 
third  or  fourth  week  ?  Half  an  inch.  Yelpeau,  how- 
ever, says  he  has  mostly  found  the  cord  about  the 
length  of  the  embryo  or  fetus,  throughout  every 
period  of  gestation  at  which  he  has  been  able  to  dis- 
sect it.  During  the  very  early  period  it  appears  like 
a  gelatinous  bag. 


GENERATION — PLACENTA.  87 

What  is  the  usual  length  of  the  umbilical  cord  of 
the  child  at  term  ?  About  eighteen  or  twenty  inches, 
though  it  is  sometimes  much  longer  or  much  shorter 
than  this. 

What  inconveniences  are  liable  to  result  from  the 
cord  being  much  longer  than  this  ?  It  is  then  apt 
to  become  tied  into  knots  by  the  various  movements 
of  the  fetus.  It  is  also  liable  to  become  prolapsed 
during  labor  when  of  greater  length  than  that  men- 
tioned. 

What  are  some  of  the  consequences  of  too  short  a 
cord  ?  Delivery  may  be  retarded,  or  the  placenta  may 
be  pulled  down,  and  hemorrhage  follow,  or  the  uterus 
may  be  inverted. 

Have  the  vessels  of  the  umbilical  cord  any  valves  ? 
No ;  an  injection  passed  into  the  arteries  will  return 
by  the  veins,  and  vice  versa. 

Is  the  cord  composed  of  these  three  vessels  only  ? 
No ;  it  has  also  a  greater  or  less  amount  of  gelatinous 
matter  in  it. 

When  you  take  hold  of  the  umbilical  cord,  how 
many  tissues  are  between  your  fingers  ?  Amnion, 
chorion,  and  the  two  arteries  and  one  vein. 

Is  the  chorion  very  intimately  attached  to  the 
cord?  Yes,  it  appears  almost  inseparable  from  the 
reticulated  tissue  which  contains  the  vessels  and  the 
gelatine. 

Is  the  cord  capable  of  bearing  much  force  applied 
to  it  ?  It  sometimes  is  broken  by  the  weight  of  the 
child  at  birth ;  but  occasionally  it  possesses  great 
strength. 

What  is  the  arrangement  of  the  membrane  in  case 
of  twins  ?  Each  embryo  has  its  own  membranes  and 
its  own  placenta,  (see  fig.  53.) 

In  cases  of  twin  ova,  when  an  ovule  is  conveyed 
into  the  uterus  by  each  fallopian  tube,  how  many  mem- 
branes are  interposed  between  each  fetus  ?  Six — 
amnion,  chorion,  decidua,  decidua,  chorion  and  amnion. 

What  number  in  case  the   two  ovules  pass  down 


88         GENERATION — SUPERFETATION. 

one   fallopian   tube  ?     Then  there  are   probably  but 
four,  viz. — amnion,  chorion,  chorion  and  amnion. 

FiV.  53. 


SUPERFETATION. 

What  opinions  are  entertained  by  most  physiolo- 
gists respecting  superfetation,  admitting  the  theory 
of  generation,  now  generally  believed  in,  to  be  cor- 
rect? That  it  would  be  impossible  for  impregnation 
to  take  place,  after  the  uterus  becomes  occupied  by  a 
decidua,  and  perhaps  also  an  ovum. 

How  are  the  facts,  however,  of  women  giving  birth 
to  two  or  more  children  at  once,  of  different  sizes,  and 
apparently  of  diff"erent  ages,  to  be  accounted  for  ? 
Upon  the  idea  that  originally  it  was  a  twin  pregnancy, 
but  that  some  cause  had  suspended  the  development 
of  one  of  the  fetuses. 

What  is  the  probable  explanation  when  the  fetuses 
are  born  at  diff'erent  periods,  and  well  developed? 
That  there  has  been  a  double  uterus,  one  of  which 
contained  the  ovum  first  fecundated,  and  the  other  the 
second. 

What  in  case  of  the  delivery  at  the  same  time  of 


GENERATION — EMBRYO.  89 

two  children,  one  white  and  the  other  black  ?  That 
the  woman  had  been  the  subject  of  two  fecundating 
copulations  in  quick  succession  by  men,  one  white, 
and  the  other  black. 

May  not  superfetation  take  place  in  cases  of  pre- 
existing extra-uterine  pregnancy  ?  It  may,  indeed, 
at  any  time  when  the  uterine  cavity  is  not  filled  with 
any  substance,  and  so  long  as  the  tubes   are  open. 

EMBRYO. 

How  long  does  the  new  being  retain  the  name  of 
embryo  ?  During  the  first,  second,  and  third  months 
of  gestation ;  for  up  to  this  period  its  formation  is  in- 
complete. 

What  is  the  earliest  period  at  which  an  embryo 
can  be  seen  within  its  investments?  About  the 
tenth  day,  and  then  only  by  the  aid  of  a  magnifying 
glass. 

What  does  it  appear  to  be  at  this  time  ?  A  mere 
amorphous  vesicle. 

Does  it  quickly  undergo  considerable  changes  ?  It 
soon  enlarges,  and  presents  two  bodies  or  vesicles  at- 
tached to  each  other. 

Of  what  are  these  two  bodies  the  elements  ?  The 
head  and  body  of  the  future  fetus. 

Which  of  these  two  bodies  or  vesicles  is  the  head  ? 
The  larger  of  the  two. 

What  does  the  embryo  resemble  in  the  next  or  se- 
cond degree  of  its  development  ?  A  kidney-bean,  or 
a  grub-worm  or  maggot  curved  upon  itself. 

What  probably  is  first  developed  in  the  embryo  ? 
Some  think  the  spine  and  the  heart. 

What  recent  English  writer  on  obstetricy,  who, 
like  Professor  Meigs  in  this  country,  has  enriched  his 
work  by  clear  illustrations  of  the  manner  in  which 
physiologists  have  observed  the  early  development  of 
the  embryo  ?     Dr.  Edward  Rigby. 

What  is  the  mode  of  addition  of  the  different  parts 
of  the  embryo,  to  constitute  the  fetus  ?     Professor 


90 


GENERATION — FETUS. 


Hodge  and  some  others  think  it  is  by  super-addition, 
puUutation  or  generation,  and  not  by  evolution,  or  un- 
folding. We  are  ourselves,  however,  inclined  to  be- 
lieve in  the  latter  mode  of  development. 

From  what  part  of  the  curved  embryo  is  this  gener- 
ation carried  on  ?  From  the  concave,  and  never  the 
convex  surface. 

What  is  the  general  order  of  succession  in  this  pro- 
cess of  pullutation  or  generation  of  parts  ;  admitting 
this  idea  to  be  correct  ?  First  the  features  appear, 
though  rather  indistinctly ;  then  the  roots  of  the  upper 
extremities,  then  the  coccyx,  and  then  the  lower  ex- 
tremities. 

Which  portion  of  the  limbs  appears  first  ?  The  arm 
and  thigh,  or  the  fore-arm  and  leg,  &c.  According 
to  those  who  believe  in  pullutation,  the  arm  and  thigh, 
and  not  the  fore-arm  and  leg,  with  the  hand  and  foot, 
as  Yelpeau  has  it. 

FETUS. 

Does  the  embryo  change  its  name  at  the  end  of 
three  months  ?     Yes ;  it  is  then  called  fetus. 

What  is  the  extent  of  its  development  at  this  time  ? 
The  teguments  are  distinct,  though  very  soft  and  rose- 
colored  ;  the  head  is  still  proportionately  very  large, 
the  nose  prominent,  though  both  the  mouth  and  eye- 
lids remain  closed :  the  osseous  system  begins  to  be 
observable,  through  the  gelatinoid  coverings,  and  the 
digits  of  the  extremities  are  quite  distinct,  and  even 
exhibit  a  surface  for  the  future  nail ;  the  intestines 
are  also  included  in  the  abdominal  varieties. 

What  is  the  length  of  the  head  and  body  of  the  fe- 
tus at  this  time  ?  From  vertex  to  coccyx,  it  measures 
about  three  inches. 

At  about  what  period  of  gestation,  does  the  muscu- 
lar S3^stem  become  sufficiently  developed,  to  exert  the 
power  of  motion  ?  From  the  middle  to  the  end  of 
the  fourth  month. 


GENERATION — FETUS.  91 


VIABILITY  OF  THE  FETUS. 


"What  is  to  be  understood  by  the  expression,  the 
viability  of  the  fetus  f  That  the  fetus,  which  has  hi- 
therto enjoyed  only  a  sort  of  vegetable  life  in  utero,  is 
now  sufficiently  developed  to  admit  of  living  indepen- 
dently of  the  uterus,  or  in  other  words,  to  enjoy  extra 
uterine  and  animal  life. 

At  what  period  of  fetal  existence  does  this  viability 
occur  ?     At  about  the  end  of  the  sixth  month. 

Are  fetuses  very  likely  to  live  when  born  at  the  end 
of  the  seventh  month  ?  It  is  the  experience  of  some 
that  they  rarely  live. 

Are  children,  born  at  the  end  of  the  eighth  month 
less  likely  to  live,  than  those  born  at  the  seventh 
month  ?  Professor  Hodge  thinks  not,  though  that 
opinion  was  entertained  by  Professor  James. 

What  is  the  condition  of  the  eye  of  a  fetus  at  seven 
months  ?  It  has  been  supposed  that  from  the  fourth 
to  the  seventh  month,  the  eye  was  closed  by  what  was 
called  the  membrana  pupillaris.  That  at  this  time  the 
membrane  bursts,  and  that  vision  becomes  possible  to 
the  child  born  at  this  time. 

What  is  Velpeau's  view  of  this  condition  of  the  eye  ? 
He  appears  to  think  that  the  iris  is  not  developed  until 
the  seventh  month,  that  it  originates  at  first  as  a  sim- 
ple ring,  which  grows  concentrically  so  as  at  last  to 
leave  the  opening  commonly  called  the  pupil  of  the 
eye. 

FETAL  ELLIPSE. 

In  what  manner  is  the  fetus  usually  situated  in  the 
cavity  of  the  uterus,  at  the  full  period  of  gestation  ? 
Its  general  form  is  that  of  an  ellipse,  its  limbs  crossed 
and  flexed  in  front  of  the  abdomen. 

What  is  the  long  diameter  of  this  ellipse  ?  From 
vertex  to  coccyx. 

What  is  its  measurement  ?     About  twelve  inches. 


92  GENERATION — FETUS. 

WEIGHT  OF  THE  FETUS. 

What  is  the  average  weight  of  a  fetus  at  term  ? 
From. seven  to  eight  pounds;  perhaps  seven  pounds 
for  the  male,  and  six  for  the  female  child.  In  Phila- 
delphia, Dr.  Hodge  weighed  one  thirteen  and  a  quar- 
ter pounds ;  and  Dr.  Condie  one,  fifteen  pounds 
nine  ounces. 

What  was  about  the  greatest  weight  noted  bj  Ma-- 
dame  Lachapelle,  in  four  thousand  cases  ?  Less  than 
twelve  pounds. 

In  twin  cases,  are  each  of"  the  children  as  large  as 
in  single  pregnancy  ?  No,  each  fetus  is  usually  smaller, 
but  the  sum  of  the  twins  is  greater  than  in  a  single 
pregnancy. 

POSITION  OF  UMBILICUS. 

Is  there  any  difference  at  different  periods  as  to  the 
point  of  insertion  of  the  umbilical  cord  ?  In  the  early 
part  of  fetal  existence  the  cord  is  inserted  near  the 
pelvis,  but  this  point  becomes  more  remote  as  the  body 
becomes  developed. 

Where  is  the  umbilical  cord  situated  at  term  ? 
About  half  way  between  the  pubes  and  ensiform  car- 
tilage. 

Do  the  viscera  of  the  fetus  bear  the  same  relation 
of  size  to  each  other  as  those  of  the  adult  ?  No — 
the  liver  is  much  larger — the  lungs  smaller  and  dense, 
they  are  very  slightly  if  at  all  porous  or  crepitous. 

THYMUS  GLAND. 

Is  there  any  structure  in  the  fetus  which  is  peculiar 
to  it,  and  useless  to  extra  uterine  life  ?  Yes — the  thy- 
mus gland. 

Where,  is  it  situated  ?  In  the  anterior  portion  of 
the  superior  mediastinum. 

How  many  lobes  has  it  ?   Two,  but  no  excretory  duct. 

Does  it  remain  developed  long  after  birth  ?  No — 
it  diminishes  rapidly  after  the  extra  uterine  functions 
become  established. 


GENERATION— FETUS.  93 

"What  is  the  object  of  the  gland  ?  Its  uses  are  not 
known. 

FETAL  HEART— CIRCULATION. 

Is  there  any  peculiarity  in  the  fetal  heart  ?  It  is 
like  a  single  heart,  both  auricles  receiving  blood  from 
the  veins,  and  both  ventricles  simultaneously  propelling 
it  into  the  arteries. 

Is  the  septum  between  the  ventricles  complete  at 
term  ?    Yes — but  it  is  imperfect  between  the  auricles. 

What  is  the  name  of  the  orifice  between  the  two 
auricles  ?     Foramen  ovale,  or  foramen  of  Botal. 

Is  there  any  valve-like  formation  connected  with  it  ? 
Yes,  there  is  an  arrangement  of  this  kind  situated  on 
the  left  side  of  the  foramen  ovale. 

How  does  the  blood  from  the  placenta  get  into  the 
fetal  heart  ?  It  enters  the  umbilicus  of  the  fetus 
through  the  umbilical  vein,  which  passes  up  under  the 
edge  of  the  liver,  where  it  empties  into  the  left 
branch  of  the  sinus  venae  portarum,  giving  off  several 
branches  to  the  liver.  Some  portion  of  the  blood 
then  passes  along  what  is  called  the  ductus  venosus, 
into  the  left  hepatic  vein,  which  runs  into  the  ascend- 
ing vena  cava.  The  blood  then  mixed  with  that  in 
the  cava,  is  carried  up  the  cava  until  it  reaches  the 
eustachian  valve,  which  directs  a  large  portion  of  it 
through  the  foramen  ovale  into  the  left  auricle,  at  the 
same  time  that  the  right  auricle  receives  the  blood 
which  comes  down  from  the  descending  cava. 

How  is  the  blood  disposed  of,  after  it  has  been  thus 
carried  into  the  heart  ?  The  two  ventricles,  supplied 
with  blood  at  the  same  instant  from  each  auricle,  now 
contract  and  force  blood  along  the  pulmonary  artery 
and  aorta. 

Is  the  pulmonary  artery  well  developed  during  fetal 
life  ?  It  is  adapted  only  to  carry  blood  sufficient  to 
nourish  the  lungs,  but  it  is  not  large  enough  to  carry 
all  the  blood  of  the  general  circulation. 

What  route  is  presented  as  a  substitute  for  the  pul- 


94  GliNERATION — FETAL   CIRCULATION. 

monary  circulation  ?  A  short  duct  is  given  oiF  from 
the  pulmonary  artery  to  the  aorta  a  little  below  its  arch. 

What  is  this  vessel  called  ?     The  ductus  arteriosus. 

How  then  is  the  fetal  blood  carried  back  to  the  pla- 
centa ?  That  which  is  forced  out  of  the  right  ventri- 
cle is  carried  through  the  ductus  arteriosus.  That 
from  the  left  ventricle  passes  the  usual  route  of  the 
arch  of  the  aorta.  At  the  point  of  insertion  of  the 
ductus  arteriosus,  the  blood  from  the  two  ventricles 
continues  to  pass  through  the  aorta  as  low  as  the  iliac 
arteries,  which  give  off  branches;  which  under  the 
name  of  internal  iliacs,  turn  upwards,  one  on  each 
side  of  the  bladder  and  pass  out  at  the  umbilicus  and 
proceed  to  the  placenta,  under  the  name  of  the  um- 
bilical arteries.  At  the  same  time,  a  sufficient  quan- 
tity is  carried  along  the  primitive  iliacs  to  nourish 
the  lower  extremities.  Fig.  54  is  a  diagram  by  Drs. 
Neill  and  Smith,  representing  the  fetal  circulation, 
which  is  thus  described :  (1)  the  umbilical  cord,  con- 
sisting of  the  umbilical  vein  and  two  umbilical  arte- 
ries, proceeding  from  (2)  the  placenta ;  (3)  the  umbilical 
vein  dividing  into  three  branches ;  two  of  which  (4) 
(4),  to  be  distributed  to  the  liver;  and  one,  (5)  the 
ductus  venosus,  which  enters  (6)  the  inferior  vena 
cava ;  (7)  the  portal  vein,  returning  the  blood  from 
the  intestines,  and  uniting  with  the  right  hepatic 
branch ;  (8)  the  right  auricle ;  the  course  of  the  blood 
is  denoted  by  the  arrow,  proceeding  from  (8)  to  (9) 
the  left  auricle  ;  (10)  the  left  venticle,  the  blood  fol- 
lowing the  arrow  to  (11)  the  arch  of  the  aorta,  to  be 
distributed  through  the  branches  given  off  from  the 
arch  of  the  aorta  to  the  head  and  upper  extremities. 
The  arrows  (12)  and  (13)  represent  the  return  of  the 
blood  from  the  head  and  upper  extremities  through 
the  jugular  and  sub-clavian  veins  to  (24)  the  superior 
vena  cava  to  (8)  the  right  auricle,  and  in  the  course 
of  the  arrow,  through  (15)  the  right  ventricle  to  (16) 
the  pulmonary  artery  ;  (17)  represents  the  ductus  ar- 
teriosus, which  appears  to  be  a  proper  continuation  of 


GENERATION — FETAL    CIRCULATION.  95 

the  pulmonary  artery ;  the  ofF-set  on  each  side  are  the 
initials  of  the  right  and  left  pulmonary  artery ;  these 
vessels  being  of  extremely  small  size  when  compared 


with  the  ductus  arteriosus.  The  ductus  arteriosus  joins 
(18,  18)  the  descending  aorta,  which  farther  down 
divides  into  the  common  iliacs,  which  become  (19)  the 
umbilical    arteries,   and    return  the  blood   along  the 


OG  GENERATION — FETAL    CIRCULATION. 

umbilical  cord  to  the  placenta,  while  the  other  divi- 
sions (20)  the  external  iliacs  are  continued  to  the  lower 
extremities.  The  arrows  at  the  termination  of  these 
vessels  mark  the  return  of  the  venous  blood  by  the 
veins  to  the  inferior  cava. 

Is  the  circulation  of  the  fetus  carried  on  within,  or 
without  the  cavity  of  its  peritonaeum  ?  Outside  of 
it  at  all  points.  This  large  membranous  sac  covers 
the  inner  and  lateral  portions  only  of  the  circulatory 
apparatus. 

CHANGES  IN  THE  "MODE  OF  CIRCU'LATION  AFTER  BIRTH. 

What  changes  take  place  in  this  circulation,  after 
the  birth  of  the  child  ?  The  air  rushes  into  the  lungs, 
upon  the  effort  to  respire ;  the  column  of  blood,  which 
before  passed  along  the  ductus  arteriosus  from  the 
right  ventricle,  now  passes  along  the  pulmonary  ar- 
tery, into  the  lungs ;  thence  it  returns  through  the 
pulmonary  vein,  into  the  left  auricle.  The  effect  of 
this  is  to  render  the  ductus  arteriosus  useless,  and  it 
consequently  becomes  filled  with  a  coagulum.  The 
current  of  blood  coursing  from  the  lungs  through  the 
loft  auricle,  closes  down  the  valvular  formation  on  the 
left  side  of  the  foramen  of  Botal  or  the  foramen 
ovale,  and  thus  cuts  off  the  direct  connection,  which 
heretofore  had  existed  between  the  right  and  left 
auricles.  From  this  moment,  the  action  of  the  heart 
becomes  double ;  that  is,  the  right  auricle  and  right 
ventricle,  act  as  it  were  independently  of  the  left 
auricle,  and  left  ventricle.  The  lungs  now  perform- 
ing the  function  of  aeration,  or  decarbonization  of  the 
blood,  the  placental  circulation  becomes  no  longer  ne- 
cessary, and  the  ductus  venosus  is  obliterated. 

What  becomes  of  the  vessels  which  were  peculiar 
to  the  fetus  ?  Upon  the  establishment  of  the  extra- 
uterine circulation,  they  become  first  obliterated  by 
coagula,  and  then  either  remain  in  the  character  of 
ligaments,  or  are  entirely  absorbed. 


GENERATION — FETUS.  97 

PHYSIOLOGICAL    CHARACTERS  OF  THE   FETUS. 

What  are  the  physiological  characters  of  the  fetus  ? 
While  yet  an  embryo,  it  grows,  is  nourished,  and  it 
has  fluids  to  sustain  it.  It  is  endowed  with  vitality 
from  the  period  of  its  detachment  from  the  ovary. 

Does  it  form  its  own  blood  ?     It  does. 

What  is  the  color  of  the  fluid  which  it  first  circu- 
lates ?     White. 

How  small  an  amount  of  red  blood  can  be  seen 
about  the  heart,  while  the  embryo  is  in  a  transparent 
or  translucent  state  ?  A  mere  drop  or  two,  about  the 
region  of  the  heart. 

Is  the  blood  of  the  fetus  exactly  like  that  of  the 
mother  ?  No,  it  is  peculiar ;  its  color  is  between  that 
of  maternal,  arterial,  and  venous  blood ;  it  is  said  to 
resemble  the  menstrual  fluid. 

Is  its  consistence  as  firm  as  that  of  adult  blood? 
No ;  its  coagulum  is  softer,  its  red  globules  are 
smaller. 

Does  it  contain  so  large  a  portion  of  phosphoric 
salts  ?     It  does  not. 

If  the  fetus  then  forms  and  circulates  its  own  blood, 
does  it  not  require  a  relatively  greater  force  to  propel 
it  through  the  placenta  and  umbilical  vessels  ?  Yes, 
and  hence  the  simultaneous  action  of  the  two  ventri- 
cles to  carry  the  blood  with  double  force. 

Does  the  blood  of  the  mother  circulate  at  all 
through  the ^ fetal  vessels?  No;  it  is  probable  that 
the  decidua  receives  blood  from  the  uterus,  but  returns 
it  again  to  that  organ  without  transmitting  it  to  the 
other  portions  of  the  placenta,  at  least  not  more  than 
to  supply  it  with  nutriment. 

Would  the  circulation  of  the  mother,  be  too  strong 
for  that  of  the  embryo  or  fetus  ?  Yes,  it  is  highly 
probable  that  it  would  destroy  it  by  the  momentum 
with  which  the  blood  would  be  impelled  into  it  if  there 
were  a  direct  communication  between  the  mother  and 
fetus. 

9 


98  .  GENERATIOX— FETUS. 

What  proofs  have  we,  that  the  maternal  blood  is  not 
circulated  in  the  fetus  ?  1.  Injections  cannot  pass 
from  the  vessels  of  the  mother  into  those  of  the  fetus ; 
nor  if  the  vessels  of  the  fetus  be  injected,  can  the 
matter  of  injection  be  conveyed  through  the  placenta 
into  the  vessels  of  the  uterus,  at  least  not  without  pre- 
vious lesion  of  structure.  2.  If  after  the  birth  of  the 
child,  the  umbilical  cord  be  cut,  there  is  no  continuous 
hemorrhage  from  the  placental  extremity  of  it, — only 
a  part  of  the  blood  it  had  contained,  is  squeezed  out 
by  contraction  of  the  uterus.  3.  The  fetus  cannot 
be  poisoned  through  the  mother.  The  child  may  die 
from  rupture  of  the  cord,  without  the  mother  being 
afiected.  4.  The  entire  ovum  has  been  thrown  oif  by 
the  uterus,  and  when  deposited  in  warm  water,  has 
been  known  to  live  many  minutes,  perhaps  an  hour  ; 
its  circulation  going  on  without  any  effusion  of  blood. 

What  eifect  does  hemorrhage  from  the  mother, 
have  upon  the  fetus  ?  None,  whatever,  directly  ;  the 
woman  may  suddenly  die  from  very  profuse  hemor- 
rhage, and  yet  the  child  will  survive  some  time ; — if 
however,  she  be  exhausted  by  constant  discharge, 
the  fetus  will  suffer  much  thus,  and  fail  to  become 
Avell  developed,  even  though  the  mother  may  survive. 

Is  the  circulation  of  the  fetus  more  rapid  than  that 
of  the  mother  ?  It  is ;  the  motions  of  the  heart 
have  been  determined  by  the  stethoscope  to  be  nearly 
or  quite  twice  as  frequent  as  tliose  of  the  mother's 
heart. 

What  part  of  the  fetus  receives  pure  placental 
blood  ?  The  left  side  of  the  liver  only,  because  every 
other  portion  has  the  blood  from  the  fetal  veins  mixed 
with  it. 

What  is  the  proportion  in  which  the  difierent  or- 
gans receive  the  placental  blood?  This  has  not  yet 
been  satisfactorily  ascertained  ;  it  may  be  proposed  as 
a  matter  of  interesting  calculation. 

Why  are  the  upper  parts  of  the  fetus  better  de- 
veloped than  the  lower  extremities  ?     Because  more 


GENERATION — FETUS.  99 

blood  is  carried  through  the  carotids  and  sub-clavians, 
than  through  the  lower  branches  of  the  aorta. 

Is  more  pure  blood  carried  into  the  left  than  into 
the  right  ventricle  ?  In  consequence  of  the  arrange- 
ment of  the  eustachian  valve,  blood  which  is  brought 
from  the  placenta,  mingled,  it  is  true,  with  a  part  of 
the  blood  in  the  portal  circulation,  is  thrown  into  the 
left  auricle  through  the  foramen  of  Botal.  From  this 
ventricle  it  is  thrown  into  the  arterial  branches  of  the 
aor4a,  which  go  to  supply  the  head  and  upper  extre- 
mities, while  the  blood  in  the  right  ventricle  is  thrown 
out  into  the  root  of  the  pulmonary  artery,  and  thence 
through  the  ductus  arteriosus  into  the  aorta,  below 
the  branches  which  supply  the  upper  portions  of  the 
body.  The  right  ventricle  receives  from  the  aorta 
the  blood  of  the  vena  cava  descendens. 

What  is  the  apparent  object  of  the  placenta  ?  To 
aiford  the  changes  necessary  in  the  blood  for  the  nu- 
triment and  development  of  the  fetus. 

What  changes  are  probably  effected  in  the  placenta? 
Those  similar  to  that  effected  in  the  lungs  by  respira- 
tion, in  other  words,  hematosis. 

Is  it  probable  that  oxygen  is  eliminated  in  the 
placenta  and  transmitted  to  the  blood  through  its 
tissue  ?  A  suppty  of  oxygen  is  necessary  to  hema- 
tosis. It  is  indispensable  to  all  animals,  to  the  chick 
in  ovo,  &c. 

Is  there  any  difference  of  color  in  the  blood  circu- 
lating in  the  vessels  of  the  fetus  ?  It  is  redder  in  the 
arteries  than  veins,  although  the  difference  is  not  so 
great  as  in  the  adult. 

How  does  pressure  upon  the  cord  cause  the  death 
of  the  fetus  ?  By  interrupting  the  process  of  hema- 
tosis, and  'not  by  suspending  the  circulation  merely, 
because  this  may  go  on,  to  some  extent  at  least,  in 
the  fetus  independently  of  a  cord  or  placenta,  or  when 
these  are  compressed. 

Is  it  probable  that  the  fluid  in  which  the  fetus  is 
suspended  affords   it   any  nutriment  ?     This  is  an  un 


100  GENERATION — FETUS. 

settled  question.  Professor  Hodge  and  some  others 
think  not.  They  suppose  that  the  placenta  is  in  some 
manner  the  medium  of  nutriment. 

ANIMAL  LIFE  OF  FETUS  DORMANT. 

Has  the  fetus  any  of  the  functions  of  animal  life  ? 
Its  faculties  are  dormant ;  although  the  different 
organs  of  this  kind  of  life  are  developed  in  succes- 
sion— as  ears,  eyes,  nose,  &c.,  yet  it  is  doubtful 
■whether  they  are  brought  into  exercise  during  intra- 
uterine life. 

What  is  the  condition  of  the  cerebrum,  during  the 
latter  part  at  least  of  fetal  life  ?  The  brain  is  soft 
and  less  consistent  at  birth  than  afterwards. 

Does  the  brain  appear  to  be  of  any  physiological 
importance  to  the  fetus  ?  No :  some  children  have 
been  born  without  any  brain,  and  yet  had  all  the 
other  organs  developed. 

Is  it  probable  that  the  fetus  has  sensation  while  in 
utero  ?  Of  the  touch  or  tact  only  ;  and  it  most  likely 
does  not  suffer  from  ordinary  compression  during  par- 
turition, as  it  is  then  probably  comatose. 

Does  it  probably  suffer  under  severe  obstetric  ope- 
rations upon  it  ?  It  is  probable  that  it  does  suffer 
from  such  causes,  since  under  such  processes  the 
pressure  is  usually  less  uniform  than  that  effected  by 
the  contractions  of  the  uterus. 

Is  there  any  probability  that  the  child  may  cry  in 
utero  ?  Not  the  least,  unless  probably  when  the 
mouth  of  the  child  can  come  in  contact  with  the 
atmospheric  air. 

OSSEOUS  SYSTEM  OF  THE  FETUS. 

What  is  the  general  condition  of  the  osseous  sys- 
tem of  the  fetus  ?  The  middle  portions  of  the  bodies 
of  the  bones  are  usually  pretty  well  developed,  though 
somewhat  flexible,  while  the  extremities  are  still  car- 
tilaginous and  very  pliant. 

What  advantages  result  from  this  circumstance  in 


GENERATION — FETUS<  101 

practice  ?  A  greater  degree  of  flexibility  ot'  the  child, 
both  during  labor,  and  for  a  short  time  after  its 
birth. 

DIMENSIONS  OF  SKELETON. 

What  is  the  usual  length  of  a  fetus  at  term  ?  From 
eighteen  to  twenty-two  inches. 

What  is  the  distance  from  the  tip  of  one  acromion 
process  to  that  of  the  other  ?     Four  or  more  inches. 

May  this  diameter  be  diminished  without  danger  ? 
It  may  be  diminished  an  inch  or  more  without  hazard 
to  the  child,  as  it  passes  through  the  pelvis. 

What  is  the  antero-posterior,  or  dorso-thoracic  dia- 
meter of  the  child  ?  Three  and  a  half  or  four  inches — 
but  it  may  be  reduced  to  two  inches. 

What  are  the  general  measurements  of  the  breech 
of  the  child  when  flexed  ?  From  trochanter  to  tro- 
chanter, from  two  and  a  half  to  three;  from  sacrum 
to  anterior  part  of  thigh  when  flexed  forward,  three 
inches. 

What  is  the  antero-posterior  diameter  of  the  pelvis 
alone  ?     From  one  and  a  half  to  two  inches. 

What  portion  of  the  fetus  is  most  important  in  an 
obstetric  point  of  view  ?     The  head. 

COMPOSITION  OF  THE  CRANIUM. 

How  is  the  fetal  cranium  constituted  ?  Of  several 
different  bones,  so  arranged  as  to  present  an  ovoid 
figure. 

How  are  the  sutures  constituted  ?  They  consist 
of  membranous  interspaces  between  the  several  move- 
able bones  of  the  fetal  head. 

How  is  the  cranium  arranged  as  to  its  compressibi- 
lity ?  Part  of  it  is  compressible,  the  bones  being 
moveable  upon,  or  capable  of  being  slided  over,  each 
other, — and  the  other  portion  is  incompressible,  or 
not  admitting  of  such  alteration  in  the  position  of  the 
bones. 

Which  of  the  cranial  bones  are  compressible  or 
9* 


102  GENERATION — FETUS. 

moveable  ?  The  occipital,  and  the  two  parietal,  and 
the  inferior  maxillary, — the  frontal  bone  is  partially  so. 

"Which  may  we  consider  as  incompressible  and  im- 
moveable ?  The  temporal,  sphenoid,  ethmoid,  malar, 
nasal,  and  superior  maxillary  bones. 

What  is  to  be  understood  by  the  term  vault  of  the 
cranium  ?  The  vault  of  the  cranium  is  composed  of 
occipital,  parietal,  and  frontal  bones. 

OVOID    FOllM— EXTREMITIES— SURFACES    OF    THE    CRA- 
NIUM. 

The  head  being  of  an  ovoid  form,  what  names  are 
given  to  the  two  extremities  of  it  ?  Posterior  and 
anterior,  or  occipital  and  mental. 

How  many  surfaces  do  we  count  upon  the  head  of 
the  fetus  ?  A  superior,  an  inferior,  two  lateral,  a 
posterior  and  an  anterior  surface. 

What  is  the  boundary  of  the  superior  surface  ?  A 
horizontal  line,  bounded  by  the  upper  part  of  the 
orbits. 

What  is  the  base  of  the  head  ?  All  the  immove- 
able part  of  it,  viz. — the  sphenoid  in  the  centre,  the 
temporal  bones  laterally,  together  with  the  bones  of 
the  face. 

What  part  of  the  fetal  head  resembles  a  hemis- 
phere ?     The  posterior  or  occipital  extremity. 

What  is  the  composition  of  the  os  frontis  ?  Al- 
though it  is  divided  nearly  or  entirely  by  a  suture 
during  early  life,  yet  it  is  usually  considered  as  one 
bone. 

How  in  regard  to  the  occipital  bone  ?  Originally 
it  was  in  several  separate  pieces,  but  these  so  soon 
become  fused  together,  that  it  is  usual  and  proper  to 
consider  it  as  only  one  bone. 

What  position  do  the  parietal  bones  occupy  ?  The 
lateral  positions  of  the  head,  above  the  temporal,  and 
between  the  frontal  and  occipital  boneS. 


GENERATION — FETUS.  103 

INTEROSSEOUS  SPACES  OR  SUTURES  IN  THE  CRANIUM. 
How  many  principal  sutures  are  there,  and  what 
are  they  called  ?  1.  The  Lambdoid  Suture^  running 
from  the  bases  of  the  occipital  and  parietal  bones, 
between  these  bones,  and  along  the  entire  lateral  and 
upper  portions  of  the  occipital  bone.  2.  The  Sag- 
gital  Suture^  extending  forward  from  the  upper  point 
of  the  occipital  bone,  between  the  two  parietal  bones, 
to  their  anterior  angles.  3.  The  Coronal  Suture^ 
extending  along  the  anterior  edges  of.  the  parietal 
bones,  between  them  and  the  frontal  bone,  from  their 
base.  4.  The  Frontal  Suture,  extending  forward  be- 
tween the  two  upper  edges  of  the  frontal  bone, 
continuous  with  the  saggital  suture  to  the  root  of  the 
nose. 

FONTANELLES. 

What  is  found  at  the  upper  and  anterior  angles  of 
the  parietal  bones,  and  at  the  upper  and  posterior  an- 
gles of  the  frontal  bone  ?  A  quadrangular  or  kite- 
shaped  membranous  space,  called  the  anterior  fonta- 
nel! e,  or  the  bregma. 

What  is  found  at  the  posterior  extremity  of  the 
saggital  suture  ?  A  triangular  or  cruciform  mem- 
branous space,  called  the  posterior  or  occipital  fon- 
tanelle. 

Is  this  posterior  or  occipital  fontanelle  always  well 
marked  on  the  fetal  head  ?  By  no  means — sometimes 
it  is  readily  perceived,  buf  more  frequently  it  cannot 
be  recognized  as  a  triangular  membranous  space— it 
is  therefore  often  merely  linear. 

Is  a  knowledge  of  these  fontanelles  of  much  impor- 
tance in  the  practice  of  midwifery  ?  They  are  of 
great  value,  as  they  are  the  chief  means  of  diagnosti- 
cating the  positions  of  the  head  during  labor. 

If  no  perceptible  membranous  space  exists  at  the 
top  of  the  occiput — how  are  we  to  recognize  the  pre- 
sentation of  the  occipital  extremity  of  the  head  ?    By 


104  GENERATIONS"—  FETUS. 

the  aTiLles  at  the  upper  and  posterior  ends  of  the  pa- 
rietal bones,  and  the  rounded  margin  of  the  occiput. 

What  other  fontanelles  may  be  found  on  the  fetal 
head  ?  Two  inferior  ones  at  the  posterior  inferior 
edges  of  the  parietal  bones,  and  between  them  and 
the  edge  of  the  occipital  bone. 

What  influence  may  these  exert  in  diagnosis  ?  With- 
out care  they  may  lead  to  error. 

What  are  the  boundaries  of  the  posterior  or  occi- 
pital surface  of  the  fetal  cranium?  From  a  point 
half  way  between  the  promontory  of  the  occiput  to 
the  foramen  magnum  of  that  bone,  round  over  the 
parietal  protuberances,  to  a  point  near  the  anterior 
extremity  of  the  saggital  suture. 

What  is  the  situation  of  the  posterior  fontanelle  in 
reference  to  the  centre  of  this  posterior  surface  ?  It 
is  not  usually  in  the  centre,  but  mostly  a  little  poste- 
rior to  it. 

VERTEX  OF  CRANIUM. 

What  is  meant  by  the  term  vertex  in  obstetrics  ? 
It  is  applied  to  that  part  of  the  fetal  head  exactly  in 
the  centre  of  the  posterior  surface  of  the  occipital 
extremity. 

What  figure  does  a  plane  of  the  occipital  extremity 
present  ?     Nearly  that  of  a  circle. 

By  what  particular  name  is  it  known  ?  Occipito- 
bregmatic  circumference. 

DIAMETERS  OF  THE  CRANIUM. 

What  is  the  transverse  diame- 
Fig.  55.  ter  of  this  circumference   called, 

and  what  does  it  measure?  The 
bi-parietal  diameter,  and  it  mea- 
sures from  three,  to  three  and  a 
half  inches,  a  to  h  fig.  b^. 

Whgt  is  the  perpendicular  dia- 
meter called,  and  vrhat  does  it  mea- 
sure ?  Occipito-bregmatic,  and  it 
measures  from  three,  to  three  and 
a    half  inches,  g  to  i  fig.  bQ. 


GENERATION — FETUS.  105 

What  is  the  horizontal  circumference  of  the  head  ? 
That  which  commences  at  the  centre  of  the  occipital 
protuberance,  and  passes  round  on  each  side  of  the 
parietal  and  frontal  bones,  till  its  ends  meet  in  the 
root  of  the  nose.     It  is  shewn  in  outline  fig.  55. 

What  is  the  long  diameter  of  this  circumference 
called,  and  what  does  it  measure  ?  Occipito-frontal, 
and  measures  four  inches,  d  to  e  fig.  56. 

What  is  the  name  of  the  transverse  diameter,  and 
what  does  it  measure  ?  Bi-parietal,  and  measures 
from  three,  to  three  and  a  half  inches,  a  to  b  fig.  55. 

What    is    the    trachelo- 
bregmatic    circumference  ?  Fig.  56. 

That  which  commences  in 
front  of  the  cervical  ver- 
tebrae, and  passes  round 
over  the  temporal,  and 
portions  of  the  parietal 
bones,  and  terminates  in 
the  bregma  or  top  of  the  __ 

head.  k^^-^    ^^ 

What  are  its  diameters 
called,   and  what   do   they  measure  ?      1.  Trachelo- 
bregmatic,  measuring  three  and  a  half  inches,  h  to  c, 
fig.  56.     2.  Bi-temporal,  measuring  two  and  a  half 
inches,  c  to  d,  fig.  55. 

For  all  practical  purposes,  what  should  w^e  consider 
the  diameter  of  the  base  of  the  cranium  ?  The  same 
as  those  of  the  occipito-mental  and  the  bi-parietal 
circumferences,  of  which  the  first  diameter  mea- 
sures five  inches,  and  the  second,  three  and  a  half 
inches. 

What  diameters  present  within  the  circumference 
of  a  perpendicular  longitudinal  section  of  the  cra- 
nium, and  what  do  they  measure  ?  1.  The  occipito- 
mental, five  inches,  a  to  b  fig.  56.  2.  The  occipito- 
frontal, four  inches,  d  to  e  fig.  56.  3.  The  occipito- 
bregmatic,  three  and  a  half  inches,  c  to  h  fig.  56. 
4.  The  trachelo-bregmatic,  three  and  a  half  inches, 
g  to  i  fig.  56. 


106  GENERATION — FETUS. 

What  is  the  situation  of  the  neck  of  the  child,  with 
regard  to  the  cranium  ?  It  is  situated  a  little  poste- 
rior to  a  vertical  line  drawn  through  the  middle  of  the 
long  diameter. 

Which  represents  the  longer  end  of  the  lever,  the 
mental  or  occipital  extremity  of  which,  the  neck  is  a 
point  or  centre  of  motion  ?    The  occipital  extremity. 

What  results  from  this  when  the  body  and  head  are 
equally  compressed  ?     A  marked  degree  of  flexion. 

What  is  the  relative  size  of  the  face  with  that  of 
the  head  ?     Very  small. 

What  is  the  facial  circumference  in  obstetric  lan- 
guage ?  From  the  top  of  the  forehead  to  the  end  of 
the  chin,  over  the  lateral  portions  of  the  malar  bones. 

What  are  the  two  diameters  of  this  facial  circum- 
ference, and  what  do  they  measure  ?  1.  The  fronto- 
mental  diameter,  measuring  three  inches.  2.  Bi-ma- 
lar,  two  and  a  half  inches. 

Where  is  the  centre*  of  this  circumference  ?  In  the 
root  of  the  nose. 

Although  the  diameters  of  the  facial  circumference 
are  smaller  than  those  of  any  other  measurement, 
what  diameters  really  are  presented  to  the  plane  of 
the  superior  strait,  in  face  presentation  of  the  fetus  ? 
The  trachelo-bregmatic,  measuring  three  and  a  half, 
and  the  bi-parietal  diameter,  measuring  three  and  a 
half  inches. 

What  obstacle  is  added  to  the  passage  of  the  head 
in  such  cases  ?  Part  of  the  neck  of  the  fetus,  mak- 
ing the  occipito-bregmatic  diameter  at  least  an  inch 
longer. 

When  the  forehead  presents  to  the  centre  of  the 
superior  strait  of  the  pelvis,  what  circumference  pre- 
sents to  that  of  the  pelvis  ?  That  which  passes  from 
the  posterior  fontanelle  round  upon  the  bi-parietal  dia- 
meter to  the  chin. 

What  is  the  long  diameter  of  this  circumference  ? 
From  chin  to  posterior  fontanelle,  measuring  from  four 
to  four  and  a  half  or  five  or  more  inches. 


PREGNANCY — FETUS.  107 

Whea  the  occiput  presents  favorably  to  ohe  of  the 
pelvic  planes,  or  which  is  the  same  thing,  when  the 
vertex  presents  to  the  centre  of  the  pelvis,  what 
circumference  prese*nts  to  that  of  the  pelvis?  The 
occipito-bregmatic  circumference,  which  includes 
the  occipito-bregmatic,  and  the  bi-parietal  diam- 
eters. 

What  relation  does  this  circumference  hold  to  the 
pelvis  in  every  stage  of  its  passage  through  the  pel- 
vis ?  Uniformly  the  same  with  the  planes  of  the 
straits  and  cavity  of  the  pelvis,  especially  when  the 
occiput  descends  on  either  of  the  anterior  inclined 
planes. 

COMPRESSIBILITY  OF  THE  CRANIUM, 

To  what  shape  is  the  compressible  portion  of  the 
fetal  cranium  reducible  ?     To  that  of  a  conoid. 

To  what  length  may  the  occipito-mental  diameter 
be  elongated  ?     From  five,  to  six  or  seven  inches. 

To  what  may  the  bi-parietal  diameter  be  dimin- 
ished by  compression?  From  three  and  a  half,  to 
three  inches. 

When  strong  compression  is  effected  upon  the  head 
in  the  pelvis,  in  what  direction  does  it  usually  carry 
the  bones  ?  The  os  frontis  and  the  parietal  bones  are 
carried  backwards,  and  the  occiput  forwards. 

DR.  MEIGS'  STATISTICS  OF  MENSURATION  OF  FETAL 
CRANIA. 

To  whom  are  we  indebted  for  the  results  of  the 
measurements  of  the  greatest  numbers  of  fetal  heads 
ever  yet  reported  in  America  ?  To  Professor  C.  D. 
Meigs. 

What  does  he  say  as  to  the  result  of  his  measure- 
ment ?  "I  have  carefully  measured  and  recorded  the 
size  of  three  hundred  crania  of  mature  children  that 
I  received  in  the  course  of  my  obstetric  practice.  In 
a  single  series  of  one  hundred  and  fifty  heads  I 
found  the  occipito  frontal  diameter  in  fifty-two  of 
them  to  exceed  five  inches.     In  11,  it  was  63^3;  in  8, 


108  GENEHATION — SIGNS    OF    PREGNANCY. 

5/5;  in  3,  it  was  5j\ ;  in  1,  S,'*^;  in  1,  5/^;  in  2, 
5/2?  ^^^  1?  5]|.  The  sum  of  my  occipito-frontal 
measurements  was  seven  hundred  and  twenty-nine 
and  seven  twelfths  of  an  inch  for  oW  hundred  and  fifty 
crania.  The  mean  was  four  inches  and  ten  twelfths. 
The  sum  of  the  bi-parietal  diameters  of  the  said  one 
hundred  and  fifty  crania,  was  five  hundred  and  eighty- 
six  inches  and  seven  twelfths — the  mean,  three  inches 
and  eleven  twelfths  of  an  inch.  The  bi-parietal  dia- 
meters exceeded  four  inches  in  sixty-eight  of  the 
children.  In  19,  it  was  4.1  ;  in  5,  it  was  4.2  ;  in  6, 
4.0 ;  in  3,  4.4 ;  in  1,  4.5  ;  in  only  one  case  was  it 
less  than  3.6,  the  usual  estimate,  and  in  that  case  it 
fell  to  3.4.  I  measured  one  hundred  and  twenty-six 
occipito-mental  diameters  of  neonati  at  term,  of  which 
the  sum  was  six  hundred  and  ninety-nine  inches  and  five 
tenths  ;  so  that  the  tnean  or  average,  of  the  one  hundred 
and  twenty-six  diameters  was  five  inches  and  a  half.  I 
know  of  no  one  who  has  measured  so  many,  and  I  am 
sure  that  greater  accuracy  is  not  to  be  attained  by 
any  person.  Upon  these  grounds,  therefore,  I  am  to 
inform  the  student  that  the  occipito-mental  diameter 
of  the  fetus,  is  five  inches  and  a  half;  the  occipito- 
frontal four  inches  and  ten  twelfths,  and  the  bi-parie- 
tal three  inches  and  eleven  twelfths.  The  above  state- 
ment ought  to  show  that  it  is  not  a  matter  of  small 
moment  whether  the  head  presents  in  labor  by  the 
vertex,  the  crown,  or  the  forehead." 

SIGNS  OF  PREGNANCY. 

Into  how  many  classes  may  the  signs  of  pregnancy 
be  divided  ?  Two — rational  or  sympathetic,  or  phy- 
siological ;  and  positive,  physical  (or  mechanical)  signs. 

What  is  usually  regarded  as  the  first  rational  sign  ? 
Suppression  of  the  menses. 

Can  this  sign  be  relied  upon  ?     Not  positively. 

What  other  causes  may  suppress  or  suspend  the 
menstrual  function  ?  Exposure  to  cold,  uterine  con- 
gestions, or  structural  diseases  of  the  organ. 


PREGNANCY — DEVELOPMENT  OF  UTERUS.   109 

Are  the  menses  always  suppressed  by  pregnancy  ? 
Not  always  during  the  first  months. 

Are  there  any  cases  in  which  women  menstruate 
only  during  pregnancy  ?  Such  cases  are  very  rare, 
but  have  been  mentioned  by  Dewees,  Daventer,  and 
Baudelocque. 

When  do  the  mammary  glands  become  sympatheti- 
cally affected  ?  One  or  two  months  after  conception, 
these  glands  enlarge,  become  the  seat  of  slight  pains 
or  pricking  sensations. 

When  do  they  begin  to  secrete  milk  ?  Usually  to- 
ward the  latter  end  of  pregnancy. 

Is  milk  never  found  in  the  mammae,  unless  the  female 
be  pregnant  or  nursing  ?  Milk  is  sometimes  secreted 
by  old  women,  and   occasionally  by  very  young  girls. 

Do  the  breasts  never  become  tumid,  or  painful,  ex- 
cept during,  or  as  a  consequence  of,  pregnancy  ? 
They  are  liable  to  become  tumid  and  painful  from 
other  causes — as  cold,  uterine  irritation,  &c. 

What  changes  do  the  nipples  or  papillae  undergo, 
during  pregnancy  ?  They  become  enlarged,  developed, 
more  tumid,  darker  colored. 

Do  any  changes  occur  in  the  areola  ?  It  becomes 
larger  and  darker  colored — in  brunettes  it  becomes 
almost  black.  The  mucous  follicles,  about  the  nip- 
ples, become  more  prominent,  and  the  veins  more  blue. 

May  not  these  changes  occur  from  other  causes  than 
pregnancy  ?  They  may  arise  from  mechanical  irrita- 
tion, as  frequent  handling,  &c. — also,  from  sympathe- 
tic irritation  in  the  uterus,  &c. 

What  changes  take  place  in  the  uterus  during  the 
early  weeks  or  months  of  pregnancy  ?  It  enlarges, 
becomes  developed,  at  first  in  all  directions. 

DEVELOPMENT  OF  THE  UTERUS  CAUSED  BY 
PREGNANCY. 

At  what  time  does  the  development  of  the  uterus 
begin  to  form  a  tumor  in  the  abdomen  ?  In  the  third 
and  fourth  months. 

10 


110   PREGNANCY — DEVELOPMENT  OF  UTERUS. 

Do  young  married  females  mostly  become  consider- 
ably developed  about  the  pelvic  region,  before  they 
are  impregnated  ?  Yes,  not  only  their  hips,  but  their 
breasts  also,  are  apt  to  become  enlarged. 

Is  there  any  diiference  in  the  direction  of  the  ab- 
dominal tumor  in  different  women,  or  in  the  same  wo- 
man at  different  pregnancies  ?  Yes — in  women  whose 
abdominal  muscles  are  relaxed,  the  uterine  tumor  is 
more  prominent. 

Is  the  tumor  of  which  we  have  been  speaking,  a 
positive  evidence  of  pregnancy?  It  is  not  a  positive 
evidence,  because  some  women  become  very  fat,  inter- 
nally, after  marriage. 

Have  women  any  power  to  conceal  the  abdominal 
development,  when  they  wish  to  appear  not  pregnant  ? 
They  can  frequently  succeed  in  doing  so,  by  their 
manner  of  carriage  and  dress. 

What  is  the  order  of  development  of  the  abdomi- 
nal tumor,  in  cases  of  pregnancy  ?  There  is  no 
great  enlargement  till  the  third  month;  at  this  time 
there  is  a  fulness  in  the  hypogastrium — at  four  months 
the  tumor  is  larger — at  five  months  the  uterus  is  above 
the  pubes,  &c. 

Is  there  any  alteration  in  the  size  of  the  abdomen 
during  the  first  two  months  ?  No — there  should  be 
no  distinct  tumor  found  in  the  abdomen  during  the 
first  and  second  months. 

•   Is  there  any  tumefaction  in  the  hypogastric  region, 
during  the  third  month  ?     Yes — there  is  usually. 

Upon  what  does  it  depend  ?  Partly  upon  the  de- 
velopment of  the  abdominal  parieties,  and  partly  upon 
the  circumstance,  that  the  intestines  are  carried  up  by 
the  fundus  of  the  uterus. 

What   is  the  general  condition  of  the  upper  and 
lateral  portions  of  the  abdomen,  at  the  third  month  ?  ^ 
It  is  flat  above,  and  rather  puffy  in  the  iliac  fossae. 

Has  this  usually  been  regarded  as  a  valuable  diag- 
nostic sign  of  pregnancy  ?     By  many,  it  has  been  so 


PREGNANCY — QUICKENING.  Ill 

considered.  The  French  have  the  adage — "  En  ven- 
tre plat,  enfant  il  j  a." 

Where  is  the  top  of  the  uterus  situated,  in  the  fourth 
month  ?  It  is  immediately  above  the  superior  strait, 
and  the  tumor  can  then  be  just  felt. 

Does  the  woman  usually  experience  a  fluctuation  or 
fluttering  about  the  end  of  the  fourth  month?  She  does. 

QUICKENING. 

What  is  this  sensation  called  ?     Quickening. 

Is  it  proper  to  regard  this  as  the  period  at  which 
the  child  becomes  quickened  into  life  ?  The  child 
is  endowed  with  life  at  all  its  stages  of  uterine  existence. 

Should  it  not  be  viewed  as  an  evidence  that  the  de- 
gree of  the  development  of  the  fetus  is  such,  that  it 
can  exert  muscular  movement  at  this  time  ?  This 
would  be  the  proper  view  to  take  of  it ;  though  some 
have  thought  that  it  arose  from  the  fact  that  the  fetus, 
capable  of  motion  at  much  earlier  periods,  now  made  its 
impression  upon  the  sensation  of  the  mother  in  conse- 
quence of  the  womb  being,  at  this  stage  of  its  develop- 
ment, in  more  intimate  contact  with  the  abdominal 
nerves. 

Is  this  period  of  quickening  always  fixed  at  four  or 
four  and  a  half  months  ?  No  ;  some  women  feel  the 
fetus  earlier,  and  some  later  than  this. 

Upon  what  does  this  diff"erence  of  time  probably 
depend?  Either  upon  difference  in  degrees  of  de- 
velopment, or  upon  the  diff"erent  degrees  of  sensibility 
in  mothers. 

When  does  quickening  realli/  take  place  ?  At  the 
time  of  conception. 

What  other  movements  take  place  during  preg- 
nancy which  is  apt  to  excite  the  attention  of  the  wo- 
man ?     The  slipping  up  of  the  uterus  out  of  the  pelvis. 

When  does  this  happen  ?  Almost  invariably  be- 
tween the  fourth  and  fifth  month. 

Does  the  occurrence  of  this  sensation  of  "  quicken- 
ing," with  the  other  signs  enumerated,  remove  all  doubts 


112  PREGNANCY — PHYSICAL   EXPLORATION. 

as  to  the  existence  of  pregnancy  ?  No — some  women 
have  all  these  signs,  and  are  not  pregnant ;  even  some 
who  think  they  not  only  feel,  but  see  the  movements  of 
the  child  through  the  abdominal  parieties. 

May  a  woman  be  pregnant,  when  none  of  these 
symptoms  occur  ?  Yes — when  if  they  have  occurred 
at  all,  they  have  been  very  slight,  and  no  motion  what- 
ever has  been  noticed. 

Where  is  the  top  of  the  tumor  in  the  fifth  month  ? 
Half  way  up  to  the  umbilicus. 

Where  at  the  sixth  month  ?     At  the  umbilicus. 

Where  at  the  seventh  month  ?  Three  fingers'  breadth 
above  the  umbilicus. 

Where  at  the  eighth  month  ?  At  the  epigastric 
region. 

Where  at  the  ninth  month  ?  It  does  not  rise  higher 
during  this  month,  but  usually  expands  more  into  the 
lateral  portions  of  the  abdomen  and  pelvis.  Towards 
the  end  of  the  gestation,  it  seems  even  to  descend  a 
little. 

Is  the  protrusion  of  the  navel  always  a  diagnostic 
sign  of  pregnancy  ?  No — though  usually  perhaps  al- 
ways present  at  certain  stages  of  true  pregnancy, 
yet  it  may  occur  from  other  causes  than  pregnancy ; 
as  the  existence  of  large  tumors,  &c. 

May  enlargements  of  the  abdomen  from  obesity 
cause  an  equal  degree  of  protrusion  ?  We  believe  that 
in  fat  women,  who  are  not  pregnant,  the  umbilicus 
is  always  sunken. 

Is  the  gait  of  a  female  altered  by  pregnancy  ?  It 
is  more  vacillating ;  the  feet  are  placed  further  apart. 

PHYSICAL  EXPLORATION. 

How  is  the  existence  of  pregnancy  to  be  verified, 
admitting  all  the  sympathetic  signs  to  be  fallacious  ? 
By  physical  examination. 

In  what  does  this  examination  consist  ?  In  exami- 
nation by  the  hand  of  the  external  surface  of  the  ab- 
domen, &c. 


PREGNANCY — TOUCH.  113 

What  is  to  be  gained  by  this  ?  A  knowledge  of  the 
size  and  kind  of  tumor  which  occupies  the  cavity, 
and  sometimes  also  of  its  contents. 

How  can  you  appreciate  the  existence  of  any  thing 
within  the  cavity  of  the  tumor,  by  such  an  external 
examination  ?  By  applying  the  bare  cold  hand  upon 
the  surface  of  the  abdomen,  a  shock  is  transmitted 
to  the  contents  of  the  uterus,  which  if  endowed  with 
vitality  will  sometimes  move  with  a  force  which  can 
be  felt. 

What  position  is  most  suitable  for  this  purpose  ? 
The  patient  should  be  on  her  back  ;  have  her  shoulders 
raised,  her  limbs  and  abdomen  flexed. 

May  she  contract  the  abdominal  muscles  ?  No ;  she 
should  keep  every  thing  as  flaccid  as  possible,  she 
should  breathe  easy,  and  make  no  straining  effort. 

Should  the  hand  of  the  examiner  be  removed  im- 
mediately after  it  has  been  applied  to  the  abdomen  ? 
No  ;  it  should  be  kept  some  moments  in  contact  with 
the  surface,  that  it  may  appreciate  any  movements 
which  may  take  place. 

Is  this  external  examination  sufiicient  to  enable  the 
accoucheur  always  to  diagnosticate  pregnancy  ?  No  ; 
it  is  liable  to  fail,   from  a  variety  of  circumstances. 

What  other  resource  is  there  ?  Examination  per 
vaginam. 

What  is  this  process  called  in  professional  language  ? 

The  touch. 

TOUCH. 

What  is  the  relative  importance  of  this  operation 
to  the  accoucheur  in  pregnancy  and  diseases  of  the 
uterus  ?  By  some  high  authority  it  is  regarded  as 
important  to  the  accoucheur  as  the  lever  to  the 
mechanic,  and  the  compass  to  the  mariner. 

What  conduct  should  the  accoucheur  observe  when 
about  to  make  this  kind  of  examination  ?  That  which 
has  regard  to  the  sense  of  delicacy  on  the  part  of 
the  female. 

10* 


114  PREGNANCY — TOUCH. 

To  whom  should  he  make  the  proposition  for  an  ex- 
amination ?  To  a  third  person,  as  a  nurse,  the  hus- 
band, or  to  some  matronly  female. 

How  should  he  dispose  of  himself,  while  such  a  pro- 
position is  communicated  to  the  patient  ?  He  should 
retire  into  another  room  until  the  decision  is  made,  un- 
less his  proposition  is  promptly  acceded  to. 

AKRANGEMENTS  FOR  PHYSICAL  EXAMINATION. 

What  arrangements  should  be  made  in  order  to 
conduct  the  examination  most  satisfactorily  ?  The 
room  should  be  darkened,  and  the  patient  dressed 
lightly,  and  placed  in  the  suitable  position. 

Should  the  physician  insist  upon  having  a  third  per 
son  present?  He  should  always  do  so  if  it  be  at  all 
practicable. 

How  should  the  patient  be  placed  ?  The  horizontal 
position  will  sometimes  answer,  though  many  advan- 
tages are  gained  by  the  erect  position. 

If  she  be  placed  in  the  horizontal  position,  upon 
what  part  of  her  body  should  she  recline  ?  When  the 
simple  touch  to  determine  the  condition  of  the  neck 
and  mouth  of  the  uterus,  is  to  be  resorted  to  only, 
she  may  recline  upon  her  left  side  : — but  if  both  exter- 
nal and  internal  examination  is  to  be  made,  she  should 
be  placed  upon  her  back  ,with  her  hips  to  the  edge  of 
the  bed,  and  her  lower  extremities  flexed,  head  and 
shoulders  considerably  raised. 

What  accommodations  should  the  nurse  furnish  for 
the  physician  ?  Several  napkins,  some  unctuous  mat- 
ter, a  chair  by  the  bed,  a  basin  of  warm  water,  soap,  &c. 

How  should  the  accoucheur  sit  ?  At  the  side  of 
the  bed,  with  his  right  hand  towards  tlie  hips  of  the 
patient,  if  she  be  on  her  ieft  side ;  but  if  on  her  back, 
he  should  sit  with  his  face  towards  her,  that  he  may 
reach  his  left  hand  to  her  abdomen. 

What  is  the  rule  for  carrying  the  hand  under  the 
coverings  ?  The  clothes  should  be  properly  raised  at 
their  lower   edges,  by  the  left  hand,  then    the  right 


PREGNANCY — TOUCH.  115 

hand,  with  the  index  finger  lubricated,  somewhat 
flexed,  and  the  thumb  erect  and  abducted  is  next  passed 
cautiously  up  under  the  clothes  without  uncovering  the 
patient. 

Supposing  your  patient  to  be  standing,  how  should 
she  be  arranged  ?  She  should  be  allowed  to  rest  her 
hips  against  something  firm,  and  then  recline  forward 
as  if  to  lean  upon  the  examiner. 

How  should  the  examiner  be  situated  ?  Either  upon 
a  low  seat,  or  resting  upon  one  knee,  in  front  of  the 
patient. 

To  what  portion  of  the  genital  fissure  should  the 
finger  be  carried  ?  Always  to  the  posterior  commis- 
sure, avoiding  contact  with  the  mons  veneris  if  pos- 
sible. When  the  finger  has  thus  gained  access  to  the 
vagina,  it  should  be  turned  to  present  its  radial  edge 
to  the  arch  of  the  pubes. 

Can  the  touch  afi'ord  us  any  good  idea  of  early 
pregnancy  ?  Yes  ;  it  may  even  then  appreciate  the 
changes  which  have  occurred  in  the  uterus. 

What  is  the  earliest  period  however  at  which  any 
positive  information  can  be  acquired  ?  After  the  fourth 
month. 

What  can  be  recognized  in  the  uterus  after  this  ? 
The  existence  of  a  body  suspended  in  a  fluid. 

BALLOTTEMENT— HOW  PERFORMED. 

What  name  has  been  given  to  the  process  by  which 
this  knowledge  is  obtained  ?  Ballottement,  or  uterine 
palpation,  or  percussion. 

How  is  this  performed  ?  By  the  application  of  the 
index  of  one  hand  to  the  mouth  or  neck  of  the  ute- 
rus, while  the  other  hand  is  applied  upon  the  abdo- 
men over  the  fundus  of  the  uterus.  The  finger  in  the 
vagina,  is  then  suddenly  to  push  up  the  part  of  the 
uterus  with  which  it  is  in  contact ;  while  the  palm  of 
the  other  hand  is  prepared  to  receive  any  impression 
which  such  a  shock  may  make  ;  the  percussing  finger 
is  to  be  kept  appUed  to  the  os  or  cervix  uteri,  that  it 


116 


PREGNANCY — AUSCULTATION. 


may  determine  whether  any  body  floating  within  the 
cavity,  descends  upon  it.  In  this  way  very  fre- 
quently it  is  possible  to  determine  the  existence  of  a 
body  within  the  uterus  and  even  to  a  certain  extent 
the  degree  of  its  development. 

Fig.  57. 


AUSCULTATION. 

What  other  means  of  diagnosis  has  the  obstetrician, 
besides  that  of  the  external  and  internal  touch  ?  Aus- 
cultation. 

What  are  we  to  appreciate  by  auscultation  ?  The 
existence  or  non-existence  of  the  vital  actions  of  the 
fetus. 

How  many  modes  are  there  of  performing  it  ?  Me- 
diately through  the  stethoscope,  or  immediately  by  the 
application  of  the  ear  to  the  surface  of  the  abdomen. 

Does  delicacy  require  that  mediate  auscultation  be 
used  in  cases  of  supposed  pregnancy  ?  It  is  cer- 
tainly most  proper  when  it  will  answer.  If  immedi- 
ate auscultation  is  resorted  to,  the  under  dress  of  the 
patient  should  be  allowed  to  cover  her  person. 

What  does  auscultation  aiford,  which  ballottement 
does  not  ?  Ballottement  determines  the  existence  or 
non-existence  of  a  body  within  the  uterus,  but  does 
not  indicate  its  vitality — auscultation  contributes 
much  to  determine  the  latter,  by  mostly  recognizing 


PREGNANCY — AUSCULTATION.  117 

the  sounds  peculiar  to  the  fetus,  &c.,  when  it  is  alive 
in  utero. 

Is  it  an  important  improvement  in  the  means  of 
ohstetric  diagnosis  ?  It  should  be  considered  as  a 
very  important  improvement  in  obstetric  diagnosis. 

How  many  sounds  are  to  be  discriminated  by  this 
auscultation  ?  Two — one  depending  upon  the  mo- 
tions of  the  fetal  heart,  and  the  other  said  to  depend 
upon  the  circulation  of  blood  in  the  placenta. 

What  is  the  difference  in  these  sounds  ?  The  first 
has  a  quick  double  beat  or  sound,  amounting  to  from 
one  hundred  and  forty  to  one  hundred  and  fifty  in  the 
minute ;  the  other  is  synchronous  with  the  actions  of 
the  maternal  heart. 

What  is  the  character  of  the  first  kind  of  sound  ? 
It  has  been  aptly  compared  to  the  ticking  of  a  watch 
under  a  pillow. 

What  is  the  character  of  the  other  sound  that  is 
heard  ?  It  is  like  the  cooing  of  a  dove,  or  like  the 
passage  of  a  fluid  through  a  great  many  cells. 

What  is  it  called  ?  Placental  soufflet,  or  placental 
sound. 

Is  it  proper  to  rely  upon  the  absence  of  the  sounds, 
as  an  evidence  of  death  of  the  fetus  ?  Not  if  other 
symptoms  of  its  vitality  present  strongly. 

Upon  what  does  the  cooing  sound  probably  depend  ? 
Not  upon  the  circulation  of  blood  in  the  placenta,  but 
upon  the  circulation  of  blood  through  the  uterine  vessels, 
about,  or  over  that  part  at  which  the  placenta  is  seated. 

May  this  sound  be  confounded  with  any  other  ? 
Yes,  with  the  pulsations  in  the  iliac  arteries,  &c. 

Is  any  caution  to  be  used,  that  the  patient's  cloth- 
ing may  not  confuse  the  sound  ?  The  friction  of  the 
patient's  dress  may  confuse  it,  unless  care  is  taken  to 
keep  it  smooth  upon  the  abdomen. 

What  may  obscure  this  sound  while  the  child  is 
actually  alive  ?  The  existence  of  the  placenta  at  the 
posterior  part  of  the  uterus ;  or  there  may  be  a  very 
fat  omentum  interposed. 


118      PREGNANCY — CONDITION    OF   VAGINA,  ETC. 

Is  it  proper  to  decide  that  pregnancy  does  not  ex- 
ist, if  this  soufflet  cannot  be  heard  ?  No — the  situa- 
tion of  the  placenta  maj  be  such,  that  although  its 
circulation  may  be  active,  it  cannot  be  heard. 

What  is  the  earliest  period  of  pregnancy  at  which 
auscultation  becomes  of  any  value  ?  Kennedy  is  re- 
ported to  have  heard  it  at  the  twelfth  week,  but  it  is 
scarcely  to  be  relied  upon,  until  at  the  end  of  the 
fourth,  or  during  the  fifth  month. 

What  is  the  condition  of  the  mother  most  favor- 
able for  auscultation,  as  regards  corpulency  ?  The 
thinner  she  is,  the  more  readily  can  the  sounds  be 
heard,  if  the  position  of  the  child  is  favorable. 

What  situation  of  the  fetus  is  most  favorable  for 
emitting  the  sounds  of  its  heart  ?  That  in  which  its 
back  is  applied  to  the  anterior  parieties  of  the  uterus. 

At  what  part  of  the  uterine  tumor  is  the  fetal 
sound  most  frequently  heard  ?  Generally  at  the 
lower  and  lateral  portion  of  the  uterus. 

What  would  modify  the  position  at  which  these 
sounds  are  most  distinctly  heard  ?  A  change  in  the 
position  of  the  child. 

Suppose  the  breech  presented  to  the  os  uteri,  where 
should  the  fetal  sound  be  most  readily  heard  ?  Higher 
up  toward  the  fundus  of  the  uterus. 

Is  auscultation  of  any  value  in  the  diagnosis  of  com- 
pound pregnancies  ?  In  twin  pregnancies,  there  would 
be  two  points  whence  the  sound  should  emanate,  one 
above  and  another  below,  or  one  on  each  side. 

Would  the  placental  soufflet,  as  it  is  called,  be  much 
altered  by  a  twin  pregnancy  ?  Not  necessarily,  espe- 
cially, if  the  placentae  were  attached  to  each  other, 
or  the  fetuses  had  one  common  placenta. 

CONDITION  OF  VAGINA,  URINE,  ETC. 
What  other  signs  have  recently  been   spoken  of  as 
evidences  of  pregnancy  ?     A  blue  appearance  of  the 
lining  membrane  of  the  vagina,  dependant   probably 
merely  upon  venous  congestion  of  the  part. 


PREGNANCY,  DURATION    OF.  119 

Is  this  to  be  regarded  as  a  certain  sign  ?  Its  evi- 
dence should  be  received  with  great  caution. 

How  should  we  regard  the  report  of  the  chemical 
changes  of  the  urine,  resulting  in  the  formation  of  a 
gelatinous  albumen  or  a  substance  called  Kiestine,  as 
an  evidence  of  pregnancy  ?  By  no  means  as  posi- 
tive, inasmuch  as  there  is  yet  much  conflicting  testi- 
mony on  this  subject. 

DURATION  OF  PREGNANCY. 

What  IS  the  usual  duration  of  pregnancy,  utero- 
gestation  or  gravidity?  Nine  calendar  months  and  ten 
days,  ten  lunar  months  or  two  hundred  and  eighty  days, 
from  the  last  appearance  of  the  catamenial  discharge. 

May  not  healthy  well  developed  children  be  born 
in  a  shorter  time  than  that  ?  There  is  strong  reason 
to  believe  that  some  fetuses  are  well  grown  and  fully 
mature  for  extra-uterine  existence  in  less  than  two 
hundred  and  eighty  days  after  conception. 

Are  there  not  numerous  instances  on  record,  suffi- 
ciently well  authenticated  to  induce  the  belief  that 
the  fetus  is  either  longer  than  ten  lunar  months  in 
being  sufficiently  developed,  or  that  it  may  be  re- 
tained in  a  viable  condition,  in  the  uterus  greatly  be- 
yond that  time  ?  The  cases  quoted  by  English,  Ital- 
ian, and  American  authorities  would  seem  to  prove 
that  healthy  children  may  be  born  between  the  two 
hundred  and  fifty-ninth,  and  the  four  hundred  and 
twentieth  days — from  the  time  of  conception. 

PRECURSORY  SIGNS  OF  LABOR. 

What  are  some  of  the  precursory  signs  that  the 
woman  has  nearly  or  quite  completed  the  term  of 
utero-gestation  ?  A  subsidence  of  the  abdominal 
tumor,  so  that  pressure  is  taken  off  from  the  epigas- 
trium, and  the  woman  feels  more  buoyant,  free,  and 
comfortable :  the  brain,  heart,  lungs,  and  all  the  su- 
perior viscera  performing  their  functions  more  readily. 

What  sensation   is   then  usually  experienced  about 


120  PREGXANCY — LABOR. 

the  pelvis?  One  of  pressure,  uneasiness,  constant  desire 
to  urinate,  or   defecate  every  ten  or  fifteen  minutes. 

LABOR. 

What  is  meant  by  the  term  labor  in  obstetric  lan- 
guage ?  It  signifies  an  effort  on  the  part  of  the  ute- 
rus and  the  mother  to  expel  its  contents. 

Is  it  to  be  regarded  as  a  mere  mechanical  action, 
or  a  vital  function  ?  It  is  a  function,  partly  depen- 
dant upon  mechanical,  though  principally  on  vital  ac- 
tion. 

How  many  kinds  of  cause  of  labor  are  there? 
Two — natural,  (or  spontaneous,)  and  accidental. 

What  is  the  actual  cause  of  labor  ?  At  present  it 
is  unknown  to  physiologists. 

What  are  accidental  causes?  All  such  as  indi- 
rectly excite  the  uterine  fibres  to  contraction,  whether 
at  full  time  or  prematurely. 

What  influence  may  excitement  or  injury  of  any 
of  the  viscera  have  upon  the  production  of  labor  ?  It 
is  mostly  liable  to  excite  the  contractions  of  the  ute- 
rus, and  thus  bring  on  labor. 

What  effect  are  violent  inflammations  of  any  of  the 
viscera,  or  any  febrile  condition  of  the  general  sys- 
tem, liable  to  have  upon  labor  ?  They  always  increase 
the  liability  to  uterine  contraction. 

Does  the  fetus  perform  any  active  part  during  la- 
bor ;  that  is,  does  it  contribute  in  any  way  by  its  own 
efforts  to  effect  its  delivery  ?  None  whatever,  unless 
in  some  cases  strong  motions  may  excite  the  contrac- 
tions of  the  uterus';  otherwise  it  is  in  this  respect  en- 
tirely passive. 

What  is  the  main  agent  in  the  process  of  labor  ? 
The  uterus. 

What  may  be  regarded  as  important  accessory 
aids  ?  The  abdominal  muscles,  the  diaphragm,  and 
indeed  all  the  voluntary  powers  of  the  mother. 

ACTION  OF  THE  UTERUS. 

What  evidences  have  we  that  the  uterus  is  the  prin- 


PREGNANCY — LABOR.  121 

cipal,  and  may  be  the  sole  agent  in  the  expulsion  of 
the  ovum  ?  Labor  has  sometimes  taken  place,  during 
sleep,  and  the  ovum  has  been  expelled  immediately 
after  the  apparent  death  of  the  patient ;  it  also  has 
happened  while  she  was  comatose  and  could  use  no 
effort. 

What  evidences  are  oifered  to  the  sense  of  touch, 
that  the  uterus  contracts  ?  If  you  place  the  hand  on 
the  abdomen  when  the  woman  complains  of  pain,  you 
can  feel  the  uterus  grow  hard  and  firm.  If  you  ap- 
ply the  finger  to  the  uterus  per  vaginam,  you  will  feel 
it  tightening  itself  up  when  the  patient  complains  of 
pain. 

Does  the  state  of  the  mind  exert  any  influence  upon 
the  contractions  of  the  uterus  in  labor  ?  Although 
uterine  contraction  is  not  subject  to  the  volition  of  the 
patient,  yet  moral  causes  may  exert  great  influence 
over  it,  sometimes  increasing  the  violence  of  the  con- 
tractions, but  more  frequently  suspending  them,  or 
rendering  them  much  more  feeble. 

What  effect  has  great  anxiety  upon  labor  ?  It  al- 
most always  retards  it,  while  on  the  other  hand,  con- 
fidence and  hope  increase  and  facilitate  it. 

To  what  part  of  the  system  may  the  excitement  of 
the  uterine  system  be  translated?  -  To  the  brain  and 
spinal  marrow. 

What  are  the  usual  consequences  of  such  a  transla- 
tion ?     Puerperal  convulsions. 

To  how  many  kinds  of  contraction  is  the  uterus  sub- 
ject ?     Two :  tonic,  and  alternate  or  spasmodic. 

What  is  to  be  understood  by  the  term  tonic  contrac- 
tion ?  A  regular  and  permanent  contraction  of  all  the 
muscular  fibres  of  the  uterus. 

What  synonyme  has  tonic  contraction  ?  Tonic 
rigidity. 

What  is  meant  by  spasmodic  contractions  of  the 
uterus  ?  Those  contractions  which  take  place  sud- 
denly, continue  a  few  minutes  and  then  subside. 

What  terms  are  synonymous  in  reference  to  the  ac- 
11 


122  PREGNANCY—BAG    OF   WATERS. 

tion  of  the  womb  in  labor  ?  Alternate  contractions, 
painful  contractions,  labor  pains,  &c.  Pains  are  not 
however,  always  proportioned  to  the  degree  of  the  con- 
tractions in  such  cases* 

Is  not  tonic  contraction  of  the  uterus  painful  ?  Not 
usually. 

What  are  its  effects  ?  It  squeezes  the  blood  from 
the  vessels,  and  regularly  diminishes  the  size  of  the 
uterine  tumor. 

Where  is  probably  the  seat  of  the  pain  during  the 
spasmodic  contraction  ?  About  the  neck  of  the 
uterus. 

What  is  the  usual  order  of  frequency  of  the  spas- 
modic or  alternate  contractions  of  the  uterus  in  labor  ? 
At  first,  about  once  in  half  an  hour,  then  gradually 
more  frequently. 

What  is  the  effect  of  these  alternate  contractions 
upon  the  uterus  ?  They  possibly  assist  to  dilate  the 
orifice,  and  do  gradually  force  out  some  portion  of  the 
ovum. 

What  effect  has  the  dilatation  of  the  os  uteri  upon 
the  long  diameter  of  the  uterus?  It  allows  its  long 
diameter  to  become  shorter. 

What  effect  has  the  dilatation  of  the  os  uteri  upon  the 
membranes  which  were  situated  over  the  cervix  and 
OS  uteri  ?  They  necessarily  become  separated  from 
their  connexion  with  that  part. 

BAG  OF  WATERS. 

What  happens  to  the  membranes,  as  the  os  uteri  be- 
comes considerably  expanded?  They  mostly  pass  out 
into  the  vagina,  and  present  what  is  usually  called,  the 
"  Bag  of  Waters." 

What  influence  does  the  presence  of  this  bag  of 
waters  usually  exert  upon  the  vagina  ?  It  distends 
it,  and  often  excites  a  copious  secretion  of  mucus. 

What  becomes  of  this  b;ig  of  waters  under  the 
continued  and  repeated  contractions  of  the  uterus  ? 
It  ruptures  or  bursts,  and  suddenly  discharges  its  con- 


PREGNANCY — ACCESSORY   POWERS.  123 

tents,  or  in  some  cases  remaining  entire,  it  is  protracted 
bejond  the  vulva,  till  the  entire  ovum  is  expelled. 

Are  you  to  expect  always  to  find  a  "  bag  of  waters" 
in  the  vagina  after  the  woman  has  been  in  labor  some 
time  ?  Not  always ;  for  it  sometimes  happens  that  the 
membranes  rupture  before  the  os  uteri  is  dilated  to 
any  extent,  but  even  when  this  does  not  happen,  the 
presenting  part  of  the  fetus  may  be  applied  so  closely 
to  the  membranes  at  the  os  uteri,  that  there  is  little 
or  no  fluid  interposed  : — again,  the  size  of  the  ovum 
may  be  so  great,  or  the  membranes  so  full,  that  it  is 
impossible  for  a  segment  of  the  contents  of  the  uterus 
to  pass  beyond  the  level  of  its  orifice  until  rupture 
takes  place. 

What  does  the  uterus  embrace,  and  act  more  directly 
upon,  as  soon  as  the  waters  are  forced  off  ?  The  fetus. 

ACTION  OF  THi;  ACCESSORY  POWERS. 

When  are  the  accessory  powers  of  the  mother  brought 
to  bear  upon  the  fetus  ?  Mostly,  soon  after  the  expul- 
sion of  the  waters. 

In  what  way  do  these  act  ?  First,  the  woman  fixes 
the  diaphragm  by  a  deep  inspiration,  and  then  sus- 
pending the  respiratory  effort,  she  contracts  the  ab- 
dominal muscles  so  as  to  bear  downward ;  then  she 
fixes  her  lower  extremities,  which  are  generally  flexed, 
by  putting  her  feet  against  some  solid  body  ;  after- 
wards she  seizes  hold  of  some  immoveable  body,  if  she 
can  reach  it,  and  thus  brings  into  action  all  her  vol- 
untary powers,  for  forcible  and  even  violently  expul- 
sive effort. 

Are  these  accessory  powers  very  important  in  some 
cases  of  labor  ?  Although  some  women  are  delivered 
by  the  contractions  of  the  uterus  solely,  yet  in  the 
greatest  number  of  cases,  these  accessory  powers 
become  indispensable  for  the  completion  of  parturi- 
tion. 

How  is  the  uterus  sustained  in  situ  during  the  pow- 
erful effort  of  the  accessory  powers  ?     The  lower  part 


124 


PKEGNANCY — STAGES    OF    LABOR. 


of  it  is  fixed  in  and  rests  upon  the  margin  of  the 
pelvis. 

Can  a  woman  excite  the  tonic,  or  bring  on  the  spas- 
modic contractions  of  her  uterus,  by  the  voluntary  ex- 
ertion of  the  accessory  powers  ?  By  the  eifort  of  the 
abdominal  muscles  she  can  frequently  stimulate  the 
uterus  into  action. 

Are  the  accessory  powers  ever  necessary  to  aid  in 
the  dilatation  of  the  os  uteri  ?  No  :  on  the  contrary, 
the  patient  should  be  prohibited  from  using  them  by 
bearing  down  during  the  dilating  process. 

What  observation  would  go  to  give  an  idea  that  the 
accessory  powers  were  not  always  completely  under 
the  influence  of  the  will  of  the  patient  ?  That  of  the 
fact,  that  when  the  child  is  pressing  against  the  os 
uteri,  or  some  of  the  soft  parts  of  the  vagina,  it  seems 
to  be  impossible  for  the  mother  to  avoid  bearing  down. 

DIFFERENT  STAGES  OF  LABOR. 

Into  how  many  stages  is  labor  usually  divided?  Three. 
What  is  the  first  stage? 
That  in  which  the  os  uteri  is 
undergoing  the  process  of  dil- 
atation sufficiently  to  permit 
the  child  to  escape  through  it. 
Fig.  58. 

What  constitutes  the  se- 
cond stage  ?  The  expulsion 
of  the  child  from  the  uterus 
through  the  pelvis  and  soft 
parts  of  the  mother. 

What  does  the  third  stage 
include  ?     The   complete  ex- 
pulsion of  the  appendages  of 
the  fetus,  viz.  :  the  placenta  and  membranes. 

What  is  the  usual  situation  of  the  fetus  in  utero,  at 
the  commencement  of  labor,  or  the  full  period  of  ges- 
tation ?  It  is  flexed  upon  itself;  its  back  being  usu- 
ally applied  to  the  anterior  portion  of  the  uterus,  its 


PREGNANCY — LABOR.  125 

occiput  towards  the  anterior  half  of  the  maternal  pel- 
vis, and  the  vertex  applied  to  the  orifice  of  the  uterus. 

Where  are  the  first  pains  of  labor  usually  felt  ?  In 
the  back,  or  hypogastric  region. 

Are  they  uniform  in  this  respect  in  the  same  women 
at  different  times  ?  No :  sometimes  they  begin  in  the 
back,  and  sometimes  in  the  lower  part  of  the  abdo- 
men. 

When  may  they  be  considered  as  most  regular  ? 
When  they  are  felt  first  in  the  back,  and  extend  round 
to  the  pubic  region. 

What  inconvenience  does^  the  woman  usually  expe- 
rience beside  the  pain  in  the  early  stage  of  labor  ?  A 
sense  of  weight  and  of  constant  inclination  to  evacuate 
the  bladder  and  bowels. 

When  does  the  woman  begin  to  express  her  desire 
to  seize  hold  of  some  support,  that  she  may  exercise 
her  accessory  powers  ?  Usually  at  the  end  of  the 
first  stage  of  labor. 

What  is  the  usual  state  of  the  mind  during  the  first 
stage  of  labor  ?     Irritable,  petulant,  desponding. 

What  is  her  physical  condition  ?  She  is  often 
chilly,  flatulent,  sick  at  stomach,  sometimes  vomiting 
small  quantities  of  food  recently  taken,  but  mostly 
little  else  than  air. 

What  is  the  popular  opinion  respecting  the  prog- 
nosis afforded  by  sick  stomach  ?  That  sick  labors  are 
easy  labors,  and  this  idea  is  usually  correct,  for  nausea 
relieves  rigidity. 

What  is  the  condition  of  the  pulse  in  the  first  stage  ? 
It  is  usually  small  and  feeble  in  the  first  stage. 

What  may  be  inferred  from  the  fact  that  there  is  a 
secretion  of  mucus  tinged  with  blood  from  the  vagina  ? 
That  the  woman  is  actually  in  labor. 

What  is  this  secretion  called  by  nurses  and  other 
women  ?     A  sliow. 

Whence  does  it  arise  ?     Probably  from  the  vessels 
which  are  ruptured  by  the  separation  of  the  membranes 
from  the  mouth  and  neck  of  the  uterus. 
11* 


126  PREGNANCY — LABOR. 

May  a  woman  have  a  great  deal  of  pain  about  the 
back  and  abdomen,  and  jet  not  be  in  labor  ?  She 
may  have  spurious,  inefficient,  though  sometimes  very- 
severe  pain. 

How  are  these  to  be  distinguished  ?     By  the  touch. 

What  sensation  do  they  communicate  to  the  finger 
of  the  accoucheur,  when  introduced  against  the  os 
uteri  ?  It  is  found  that  tlie  uterus  does  not  contract 
at  all,  or  if  at  all,  the  contractions  are  not  accompa- 
nied by  dilatation  of  the  os  uteri. 

Is  the  dilatation  of  the  os  uteri  regular  and  uniform, 
or  does  it  progress  more  rapidly  at  one  time  than 
another  ?  It  usually  dilates  very  slowly  at  first,  but 
afterwards  more  rapidly. 

What  is  the  usual  shape  of  the  os  uteri  during  la- 
bor ?  At  first  it  is  round,  but  as  it  dilates,  it  assumes 
the  shape  of  the  part  of  the  fetus  which  is  about  to  en- 
gage in  it. 

PROGNOSIS  BY  TOUCH. 

What  prognosis  can  be  founded  upon  the  condition 
presented  by  the  os  uteri  to  the  touch  ?  It  is  very 
uncertain  ;  as  a  general  rule,  when  the  os  uteri  is  soft 
and  fleshy,  though  somewhat  thick,  the  dilatation  will 
proceed  rapidly. 

What  may  be  expected,  when  you  find  the  os  uteri 
firm  and  thin  ?  Generally,  that  the  labor  will  be  slow 
in  its  first  stage. 

Can  these  conditions  be  relied  on  with  any  confi- 
dence ?  No  :  practitioners  of  long  experience  are 
often  disappointed  in  them.  ^ 

What  is  the  best  mode  of  testing  the  degree  of  dila- 
tion at  each  pain  ?  The  application  of  the  finger  in 
contact  with  the  os  uteri  during  several  successive  con- 
tractions. 

AVERAGE  DURATION  OF  LABOR. 
What  is  the  average  duration  of  labor  ?     From  com- 
putations made  by  Dr.  Meigs,  who  has   superintended 


PREGNANCY — LABOR.  127 

very  many  cases,  the  average  duration  of  labor  is  four 
hours,  the  number  of  labor  pains  is  about  fifty,  they 
last  each  about  half  a  minute  ;  so  that  the  parturient 
woman  really  suffers  from  the  uterine  contractions 
about  twenty-five  minutes,  and  these  twenty-five  min- 
utes are  distributed  through  the  four  hours  of  a  labor 
of  mean  duration. 

RELATIVE  DURATION  OF  THE  DIFFERENT  STAGES. 

What  portion  of  the  whole  duration  of  labor,  is 
usually  occupied  by  the  first  stage  ?  About  ten- 
twelfths. 

What  for  the  second  or  expulsive  stage  ?  About  one- 
ninth. 

What  for  the  third  stage,  or  complete  expulsion  of 
the  placenta,  &c.  ?     One  twenty-fourth. 

CONDITION  INCIDENT  TO  THE  DIFFERENT  STAGES  OF 
LABOR. 

Does  the  first  stage  involve  mother  or  child  in  dan- 
ger ?  Not  necessarily,  unless  the  membranes  rupture 
prematurely ;  then  the  child  may  sometimes  suffer 
from  the  severity  and  frequent  repetition  of  the  con- 
tractions. 

May  either  mother  or  child,  incur  any  risk  during 
the  second  stage  ?  The  mother  rarely  incurs  any 
hazard,  unless  there  be  great  physical  obstacles  to  the 
success  of  the  effort,  or  some  disturbance  occur  in  her 
nervous  or  vascular  system,  but  the  child  may  be  said 
to  be  in  imminent  danger,  in  many  cases. 

What  accident  may  happen  to  it  ?  It  may  become 
apoplectic  from  the  forcible  pressure  of  the  uterus 
upon  it,  while  its  head  is  retained  in  the  pelvis,  pr  if 
expelled  too  rapidly,  it  may  be  in  a  state  of  asphyxia. 

Is  the  mother  subjected  to  any  danger,  during  the 
third  stage  ?  Her  danger  at  this  time  is  often  immi- 
nent; hemorrhage,  inversion  of  the  uterus,  &c.,  are 
liable  to  occur. 

What  sort  of  pains  usually  characterize  the  first,  or 


128  PREGNANCY — LABOR. 

dilating  stage  of  labor  ?  They  are  usually  described, 
as  cutting,  grindiyig,  or  tearing  pains. 

In  what  respect  do  those  of  the  second  stage  differ? 
They  a,refo7'cing,  hearing  down,  expulsive. 

What  position  does  the  woman  usually  assume  du- 
ring the  first  stage,  if  unrestrained  by  the  presence 
of  those  around  her  ?  She  will  sit,  stand,  or  walk 
about ;  sitting  or  kneeling  down  only  when  she  has  a 
pain. 

What  attitude  does  she  usually  assume,  when  in  the 
second  stage  ?  She  mostly  prefers  to  lie  down,  flex 
her  body  and  lower  extremities,  but  extend  her  arms 
to  embrace  something,  with  which  to  support  the  bear- 
ing down  effort  she  is  about  to  make. 

What  is  her  physical  condition  during  the  second 
stage  ?  Her  pulse  becomes  excited  both  by  the  effort, 
and  the  occasional  suspension  of  respiration.  She  is 
mostly  bedewed  with  perspiration,  and  when  a  pain 
comes  on,  her  face  becomes  florid,  sometimes  almost  livid. 

Is  the  increase  of  the  pulse  necessarily  owing  to 
febrile  excitement  ?  No ;  it  is  the  result  of  exercise, 
and  should  be  distinguished  from  the  pulse  of  inflam- 
mation. 

What  are  some  of  the  consequences  of  this  effort  ? 
Mostly  an  increased  secretion  of  serum  from  the 
skin,  and  mucus  from  the  cavities ;  occasionally,  also, 
ecchymosis  of  the  conjunctiva,  epistaxis,  and  even 
apoplexy,  or  cerebral  congestion. 

What  consequences  often  result  if  the  secretions  do 
not  increase  under  this  effort  ?  The  patient  is  almost 
sure  to  become  febrile. 

What  is  the  condition  of  the  mind,  during  the  second 
stage  ?  It  is  more  calm  and  confident,  the  patient 
now  often  solicits  the  return  of  pains,  and  she  rarely 
now  imagines  that  she  w^ill  die  before  labor  is  accom- 
plished. 

What  disturbance  is  she  liable  to  experience  in  her 
lower  extremities,  in  this  stage  ?  Severe  cramps  and 
pains. 


PREGNANCY — LABOR.  129 

Why  do  these  take  place  ?  In  consequence  of  the 
pressure  exerted  by  the  child's  head  upon  the  sacral 
nerves. 

What  condition  of  the  brain  may  supervene  in  this 
stage  of  labor  ?     Delirium  or  mania  may  ensue. 

What  urgent  sensation  takes  place  when  the  pre- 
senting part  of  the  child  is  brought  in  contact 
with  the  perinseum  ?  An  impulse  to  evacuate  the 
bowels. 

Should  the  patient  be  allowed  to  rise  to  comply 
T»ith  such  a  desire  ?  It  would  be  unsafe,  as  well  as 
unavailing  for  her  to  rise  for  that  purpose  at  this  stage 
of  the  labor. 

To  what  extent  does  the  perinseum  usually 
stretch  over  the  presenting  part  of  the  child  ?  Gene- 
rally sufficient  to  cover  the  part  presenting. 

What  takes  place  in  reference  to  both  the  moral  and 
physical  condition  of  the  patient,  immediately  after 
the  extrusion  of  the  child  ?  The  uterine  pains  now 
usually  at  once  subside  ;  the  woman,  in  an  ecstacy 
of  gratitude  expresses  herself  relieved ;  her  moral 
sensibilities  are  sometimes  wTought  up  to  their  highest 
degree. 

What  usually  occurs  soon  after  this  ?  The  uterus 
again  contracts  for  the  purpose  of  expelling  the  pla- 
centa. 

How  many  steps  or  stages  are  there  for  the  expul- 
sion of  the  appendages  of  the  fetus  ?  Usually  three  ; 
one  in  which  the  separation  of  the  placenta  is  effected, 
and  the  other  in  which  is  thrown  into  the  vagina,  and 
the  third,  in  which  it  with  the  membranes  is  expelled 
from  the  vagina. 

By  what  power  is  the  placenta  usually  expelled 
from  the  vagina  ?  By  the  voluntary  powers  of 
the  mother  alone,  unless  aided  by  the  hand  of  an 
assistant. 

What  amount  of  hemorrhage  usually  attends  the 
expulsion  of  the  placenta,  under  most  favorable  cir- 
cumstances ?     Perhaps  half  a  pint,  rather  more  or  less. 


130  PREGNANCY — LABOR. 

Suppose  hemorrhage  should  become  profuse,  m 
what  length  of  time  might  it  destroy  the  life  of  the 
mother  ?  It  is  asserted  by  very  respectable  authority, 
that  it  would  require  only  five  or  six  minutes. 

Whence  does  this  blood  escape  ?  From  the  patu- 
lous orifice  of  the  large  veins,  opposite  to  the  point  at 
which  the  placenta  was  situated. 

What  are  the  sources  of  danger,  during  the  third 
stage  of  labor  ?  Simple  exhaustion  from  the  severe 
efforts  made  during  the  second  stage,  but  particularly 
from  hemorrhage. 

What  would  you  call  a  tedious  labor  ?  One  which 
occupies  twenty-four  or  more  hours. 

What  are  some  of  the  causes  of  tedious  labor  ? 
Rigidity  of  the  soft  parts,  small  size  of  the  pelvis,  or 
deviations  of  the  presenting  part  of  the  child ;  want 
also  of  regular  action  of  the  uterus. 

What  is  the  usual  and  proper  direction  of  the  ute- 
rine forces  ?  Such  as  to  propel  the  contents  down- 
ward and  a  little  backward,  in  the  direction  of  the 
axis  of  the  superior  strait  of  the  pelvis. 

How  is  the  direction  of  the  uterus  modified  by  the 
efi*ort  of  contraction  ?  It  is  carried  more  and  more 
into  a  line  with  the  axis  of  the  superior  strait. 

What  is  to  be  understood  by  the  term  floor,  or  bot- 
tom of  the  pelvis  ?  The  lower  end  of  the  sacrum, 
the  whole  of  the  coccyx,  and  the  peringeum. 

When  the  presenting  part  of  the  child  is  carried 
down  to  this  part,  what  direction  has  it  next  to  take  ? 
It  must  be  propelled  forwards  along  the  curvature  of 
the  coccyx  and  perinaeum. 

GENERAL  CLASSIFICATION  OF  LABOR. 

How  are  labors  usually  classified  ?  Into  rapid,  slow, 
easy,  difiicult  or  laborious,  assisted  or  unassisted,  ma- 
nual and  instrumental,  simple  and  complex,  natural 
or  unnatural,  eutocia  and  dystocia. 

What  conditions  are  necessary  for  the  performance 
of  natural  labor  ?     The  uterus  should  contract  regu- 


PREGNANCY — LABOR.  131 

larly,  the  child  present  favorably,  and  that  the  pelvis 
be  sufficiently  large,  and  the  soft  parts  of  the  mother 
be  sufficiently  relaxed. 

PRESENTATION  AND  POSITION. 

What  do  obstetricians  mean  by  the  word  presenta- 
tion ?  That  some  portion  of  the  contents  of  the 
ovum  becomes  situated  at  the  orifice  of  the  uterus,  at 
or  near  the  centre  of  the  pelvis. 

What  is  meant  by  the  phrase  position  of  tJie  fetus 
in  midwifery  ?  That  some  part  of  the  presentation 
is  directed  towards  some  particular,  or  specified  part 
of  the  maternal  pelvis. 

CLASSIFICATION  OF  PRESENTATIONS. 

How  are  natural  labors  classified  as  to  presentation  ? 
First,  into  those  in  which  the  cephalic  extremity  of  the 
fetal  ellipse  presents  favorably ;  and  secondly,  into 
those  in  which  the  pelvic  extremity  presents  to  the 
pelvis   of  the  mother. 

Why  does  the  cephalic  extremity  present  most  fre- 
quently ?  Probably,  1.  Because  the  head  is  heavier  than 
any  other  equal  bulk  of  the  body,  and  therefore  descends 
in  the  liquor  amnii.  2.  Because  in  the  formation  of 
the  peculiar  figure  of  an  ellipse  the  cephalic  extremity 
is  better  adapted  to  the  small  extremity  of  the  ovoid 
cavity  of  the  uterus. 

GRAND  VARIETIES  OF  OCCIPITAL  POSITION. 

How  many  grand  varieties  of  occipital  positions  are 
there  ?  Two.  First,  in  which  the  occiput  presents 
to  some  part  of  the  anterior  half  of  the  circle  of  the 
superior  strait.  Second,  in  which  the  occiput  pre- 
sents to  some  part  of  the  posterior  half  of  the  supe- 
rior strait. 

Why  is  it  preferable  that  the  occiput  present  to  the 
anterior  semicircle  of  the  pelvis,  in  case  of  cephalic 
presentations?  Because  the  head  can  then  most 
readily  descend  along  the  planes  of  the  pelvis,  and  by 


132  PREGNANCY — LABOR. 

easy  movements  upon  the  neck,  pass  out  under  the 
arch  of  the  pubes. 

PARTICULAR  POSITIONS  OF  CEPHALIC  EXTREMITY. 

How  many  positions  of  the  head  are  generally 
recognized  ?  Six — of  which  three  are  anterior,  and 
three  are  posterior. 

What  is  the  first  position  of  the  occiput  ?  That  in 
which  the  occiput  present  to  that  portion  of  the  linea- 
ilio-pectinea,  which  is  within  the  left  acetabulum,  and 
at  the  same  time  the  sinciput  or  bregma  presents  to 
the  right  sacro-iliac  symphysis. 

What  diameter  of  the  child's  head  corresponds  to 
the  different  parts  of  the  pelvis,  in  the  first  position  ? 
The  occipito-bregmatic  diameter  of  the  head,  corres- 
ponds to  that  oblique  diameter  of  the  pelvis,  which 
extends  from  the  left  acetabulum  to  the  right  sacro- 
iliac symphysis — the  bi-parietal  diameter  of  the  head 
corresponds  to  the  other  oblique  diameter  of  the  pel- 
vis. The  occipito-mental  diameter  of  the  head,  cor- 
responds to  the  axis  of  the  superior  strait,  and  upper 
part  of  the  cavity  of  the  pelvis,  (see  fig.  59.) 

Fig.  59. 


What  is  the  second   position  ?     The  occiput  is   to- 
wards the  right  acetabulum ;  the  sinciput  toward  the 


PREGNANCY — LABOR.  183 

left  sacro-iliac  symphysis  ;  the  occlpito-bregraatic  dia- 
meter, therefore,  corresponds  to  this  oblique  diameter 
of  the  pelvis,  while  the  bi-parietal,  also,  corresponds  to 
the  other  oblique  diameter.  The  occipito-mental  dia- 
meter corresponds  to  the  axis  of  the  pelvis.  (Fig.  60.) 

Fig.  60. 


What  is  the  third  ?  The  occiput  is  directed  to  the 
symphysis  pubes,  and  the  sinciput  to  the  sacrum.  The 
occipito-bregmatic  diameter  of  the  head,  therefore, 
corresponds  to  the  antero-posterior  or  sacro-pubal 
diameter  of  the  pelvis ;  the  bi-parietal  diameter  of 
the  head  to  the  transverse  diameter  of  the  superior 
strait  of  the  pelvis  ;  the  occipito-mental  diameter  cor- 
responds to  the  axis  of  the  pelvis. 

What  is  the  fourth  ?  The  occiput  is  directed  to  the 
right  sacro-iliac  junction  ;  the  sinciput  or  the  bregma- 
tic,  to  the  left  acetabulum.  Hence  the  occipito-breg- 
matic diameter  corresponds  to  this  diameter,  and  the 
bi-parietal  diameter  of  the  head  to  the  other  oblique 
diameter  of  the  pelvis.  The  occipito-mental  diameter 
corresponds  nearly  or  quite  to  the  axis  of  the  pelvis. 
(Fig.  61.) 

What  is  the  fifth  ?     The  occiput  is  directed   to  the 

left  sacro-iliac  symphysis ;  the   sinciput  or  bregma  to 

the  right  acetabulum.     Hence  the  occipito-bregmatic 

diameter   corresponds  to  this  oblique  diameter  of  the 

12 


134  PREGNANCY — LABOR. 

pelvis,  while  the  bi-parietal  does  to  the  other  oblique 
diameter.     The  occipito-mental  diameter  of  the  head 

Fig.  61. 


corresponds  to  the  axis  of  the  superior  strait.     (Fig. 
62.) 

Fig.  C2. 


What  is  the  sixth  ?  The  occiput  is  directed  to  the 
sacrum,  and  the  sinciput  or  bregma  to  the  symphysis 
pubes.  The  occipito-bregmatic  diameter  corresponds 
to  the  sacro-pubal  or  antero-posterior  diameter  of  the 
superior  strait  of  the  pelvis ;  the  bi-parietal  diameter 
corresponds  to  the  transverse  diameter  of  the  pelvis, 
and  the  occipito-mental  diameter  corresponds  nearly 
or  entirely  with  the  axis  of  tlie  superior  strait. 


TREGNANCY — LABOR. 


135 


FLEXION. 

•  What  technical  term  is  used  to  describe  that  move- 
ment executed  upon  the  child  by  the  contractions  of 
the  uterus,  by  which  the  thorax  and  chin  are  brought 
into  contact,  and  the  occipito-mental  diameter  of  the 
head,  is  made  part  of  the  long  diameter  of  the  fetal 
ovoid  or  ellipse  ?     Flexion. 

ROTATION. 

What  influence  do  the  inclined  planes,  the  sacrum, 
coccyx,  and  perinceum  exert  upon  the  head  of  the 
child  under  the  continued  contractions  of  the  uterus? 
In  the  first  position,  the  occiput  is  compelled  to 
respond  to  the  inclination  or  spirality  of  the  left  ante- 
rior plane  till  it  appears  under  the  arch  of  the  pubis. 

Fig.  63. 


(Fig.  63.)    In  the  second  position,  it  is  obliged  to  pass 
on  the  right  anterior  plane  till  it  reaches  the   same 


136  PREGNANCY — LABOR. 

point.  In  the  fourth  position,  the  occiput  is  passed 
on  the  right  posterior  plane  to  the  middle  line  of  the 
sacrum,  while  in  the  fifth  position,  it  passes  on  the 
left  posterior  plane  to  the  same  point. 

What  is  the  movement  just  described  called?  Rota- 
tion. 

Does  rotation  take  place  in  the  third  and  sixth  po- 
sitions ?  No ;  in  these  positions  the  occiput  passes 
so  nearly  down  upon  the  anterior  or  posterior  median 
line  of  the  pelvis,  that  no  rotation  is  perceptible. 

EXTENSION. 

What  happens  to  the  head  when  it  has  reached  the 
floor  of  the  pelvis,  during  process  of  parturition  ? 
In  the  occipito  anterior  position,  as  soon  as  the  sinciput 
has  been  impinged  upon  the  sacrum,  it  is  driven  for- 
ward along  the  arc  of  the  sacrum,  coccyx  and  perinaeura, 
and  the  occiput  pressed  against  the  legs,  and  some- 
times the  crown  of  the  arch  of  the  pubes.  It  thus 
undergoes  the  movement  of  extension^  as  shewn  in  fig. 64. 

Fig.  64. 


In  occipito-posterior  positions,  when  the  occiput 
comes  to  the  floor  of  the  pelvis,  it  is  propelled  along 
the  same  parts  of  the  sacrum,  coccyx,  and  perinaeum, 
and  the  sinciput,  forehead,  and  face  are  forced  against 


PREGNANCY — LABOR.  137 

the   anterior  part  of   the  pelvis,   and  thus  the  head 
has  to  be  subjected  to  increased  flexion.  See  fig.  Qb. 


How  does  the  child's  head  pass  through  the  infe- 
rior strait?  The  occipito-mental  diameter  corres- 
ponds to  the  axis  of  the  inferior  strait ;  the  occipito- 
bregraatic  to  the  antero-posterior,  or  coccy-pubal 
diameter;  the  transverse  diameter  of  the  head  to  the 
transverse  or  bis-isqhiatic  diameter  of  the  mother. 

When  does  expansion  of  the  perinseum  begin  to 
take  place  ?  As  soon  as  the  bead  fairly  engages  in 
the  inferior  strait. 

What  is  this  expansion  called  ?  The  perinaeal 
tumor. 

To  what  degree  does  the  perinseum  become  ex- 
panded ?  Sometimes  till  it  is  large  enough  to  cover 
the  whole  cranium. 

When  may  extension  of  the  child's  head  be  con- 
sidered as  perfect  ?  Just  as  the  face  or  occiput  is 
clearing  the  perinaeum. 

When  does  the  perinaeum  offer  the  greatest  resist- 
ance to  the  escape  of  the  child  ?  At  the  time  in  which 
the  parietal  protuberances  are  about  to  escape. 

RESTITUTION. 

What  takes  place  in  regard  to  the  position  of  the 
12* 


138  PREGNANCY — LABOR. 

head,  after  it  clears  the  perinseum  ?  Restitution^  in 
which  the  head  of  the  child  takes  the  oblique  position 
at  right  angles  with  the  direction  of  the  shoulders. 

ROTATION  OF  THE  SHOULDER. 

What  change  of  positions  do  the  shoulders  undergo  ? 
They  rotate  on  the  inclined  planes.  One  shoulder  to 
get  in  front  of  the  sacrum,  and  the  other  behind  the 
symphysis  pubes. 

What  direction  does  the  head  assume  as  the  shoul- 
ders become  engaged  under  the  symphysis,  and 
in  front  of  the  sacrum  ?  The  occiput  presents  to  the 
left  tuberosity  of  the  ischium,  and  the  chin  towards 
the  right,  in  the  first  and  fifth  positions,  and  the  occi- 
put towards  the  tuber  of  the  right  ischium,  and  the  chin 
towards  the  left,  in  the  second  and  fourth  positions. 

Do  the  shoulders  engage  in  the  same  inclined  planes 
in  which  the  occiput  did  ?  No ;  always  in  the  opposite 
ones. 

What  change  takes  place  in  the  axis  of  the  body  of 
the  child  as  the  shoulders  escape  ?  The  body  curves 
upon  its  axis  laterally  to  accommodate  itself  to  the 
curvature  of  the  axis  of  the  pelvis. 

What  part  of  the  child  offers  the  greatest  resist- 
ance to  the  delivery  in  cephalic  presentations?  The 
head. 

What  other  portion  offers  the  next  degree  of  diffi- 
culty ?     The  shoulders. 

Which  shoulder  is  delivered  first  ?  In  cases  of 
easy  labor  the  pubal  shoulder  first,  but  in  cases  of 
great  rigidity  of  the  perinseum,  the  pubal  shoulder  is 
frequently  thrown  back  under  or  behind  the  symphy- 
sis, and  the  sacral  shoulder  thrown  out  first. 

Do  the  same  diameters  of  the  child's  head  present  to 
the  same  planes  of  the  pelvis,  in  the  second  as  in  the 
first  position  of  cephalic  presentation  ?  The  measure- 
ments are  the  same  in  both  cases,  but  the  occipital 
and  biparietal  diameters  are  changed  about  one  fourth 
of  a  circle. 


PREGNANCY — LABOR.  139 

What  circumstance  offers  the  only  interference  to 
as  ready  a  delivery  in  the  second  as  in  the  first  posi- 
tion ?  The  presence  of  the  rectum,  sometimes  im- 
pacted with  feces. 

Which  way  does  the  occiput  present  after  restitu- 
tion has  taken  place  in  the  second  position  ?  To  the 
right  side. 

Does  rotation  occur  quite  as  readily  in  the  second 
as  in  the  first  position  ?  When  the  rectum  is  dis- 
tended with  feces,  rotation  does  not  in  some  cases 
take  place  so  readily. 

What  difficulty  does  the  third  position  present 
which  is  not  experienced  in  the  first  and  second  po- 
sitions ?  The  fact  that  it  has  the  occipito-bregmatic 
and  part  of  the  time  the  occipito-frontal  diameter, 
presenting  to  the  short  or  antero-posterior  diameters 
of  the  superior  strait  of  the  pelvis. 

Does  rotation  of  the  head  take  place  in  the  third 
position  ?  It  does  not  usually,  if  it  enters  the  pelvis 
in  that  direction. 

Do  the  shoulders  rotate  ?     They  mostly  do. 

Does  restitution  of  the  child's  head  take  place  in 
the  third  position  ?  No ;  or  at  least  only  to  a  less 
extent  than  in  either  of  the  others,  or  only  so  far  as 
the  return  of  the  chin  towards  the  thorax  may  be 
included  in  the  meaning  of  the  word  restitution. 

Why  is  the  first  position  more  frequent  than  the 
second  or  others?  It  is  not  easily  accounted  for, 
though  some  think  it  is  dependent  upon  the  position 
of  the  upper  portion  of  the  rectum. 

Is  the  second  position  any  more  unfavorable  than 
the  first  ?  Yes ;  owing  to  the  slightly  greater  degree 
of  difficulty  of  rotation  of  the  head,  in  consequence 
of  the  situation  of  the  rectum  on  the  left  side  of  the 
sacrum. 

Why  are  the  third  positions  uncommon  ?  Because  of 
the  difficulty  of  retaining  two  convex  surfaces,  the  sinci- 
put and  the  promontory  of  the  sacrum  in  contact  with 
each  other. 


140  PREGNANCY — LABOR. 

"What  peculiar  difSculty  is  liable  to  present  in  cases 
of  the  third  position  ?  The  pressure  of  the  anterior 
fontanelle  against  the  promontory  of  the  sacrum. 

How  do  the  shoulders  rotate  in  cases  of  third  posi- 
tion ?  Either  right  or  left  comes  under  each  of  the 
pubes. 

Why  is  the  fourth  position  more  frequent  than 
the  fifth  ?  Probably  for  the  same  reason  which 
renders  the  first  more  frequent  than  the  second  posi- 
tion. 

What  is  the  opinion  of  Naegele  and  some  others, 
respecting  the  relative  frequency  of  the  occipito-right 
sacroiliac,  or  so  called  fourth  position  ?  That  it  oc- 
curred so  oftQii,  as  to  be  entitled  to  the  second  place 
of  a  proper  enumeration  of  the  positions  of  the  oc- 
ciput. 

What  is  the  mechanism  of  the  labor  in  the  fourth 
position  ?  First,  flexion  takes  place,  though  perhaps 
to  a  less  degree  than  in  the  anterior  varieties ; — then 
the  occiput  •  rotates  along  the  right  posterior  inclined 
plane ;  flexion  is  now  increased,  and  the  forehead  is 
thrown  behind  the  arch  of  the  pubis.  No  extension 
can  take  place  until  the  occiput  has  passed  over  the 
whole  length  of  the  sacrum,  and  the  forehead  has 
passed  out  under  the  arch  of  the  pubes. 

What  other  parts  than  the  head  and  neck  are  in- 
volved in  flexion,  as  the  child  enters  the  cavity  of  the 
pelvis  ?     The  thorax  and  shoulders. 

What  conditions  are  necessary  in  this  case  for  favor- 
able delivery  ?  That  the  parts  of  the  mother  be  very 
much  relaxed,  or  the  child  small. 

What  accident  is  liable  to  happen  to  the  mother,  as 
the  head  passes  from  the  inferior  strait  ?  Rupture  of 
the  perinseum. 

Is  the  bladder  more  likely  to  suffer  in  these  than  in 
occipito-anterior  positions  ?  Towards  the  latter  stages 
of  labor  it  is  liable  to  great  distension  from  the  forci- 
ble pressure  of  the  anterior  part  of  the  head. 

What  change   takes    place   in  regard  to  the  head 


PREGNANCY — LABOR.  141 

after  it  has  cleared  the  perin?eum  in  occipito  poste- 
rior positions  ?     Revolution  backwards. 

Which  way  does  the  face  of  the  child  turn  when  it 
has  cleared  the  inferior  strait  in  the  fourth  position  ? 
Towards  the  left  thigh  of  the  mother. 

Under  what  circumstances  may  the  forehead,  and 
not  the  anterior  fontanelle,  come  out  under  the  arch 
of  the  pubes  ?  When  the  child  is  small,  or  the  peri- 
nseum  much  relaxed,  or  the  coccyx  very  moveable. 

In  what  direction  do  the  contractions  of  the  uterus 
carry  the  head  of  the  child  in  the  early  period  of  the 
second  stage  of  labor  ?  Directly  down  into  the  hol- 
low of  the  sacrum. 

What  inconvenience  arises  in  reference  to  the  body 
A  the  child  ?  In  the  posterior  varieties  the  child's 
spine  bends  under  the  contractions  of  the  uterus,  and 
therefore,  the  expulsive  powers  are  less  efficient  than 
in  the  anterior  position. 

What  is  the  mechanism  of  the  fifth  position  ?  The 
bi-parietal  and  occipito-bregmatic  diameters,  corres- 
ponding to  the  oblique  diameters  of  the  superior 
strait,  the  contractions  of  the  uterus  force  the  occi- 
put down  along  the  left  posterior  inclined  plane,  and 
the  bregma  along  the  right  anterior  plane. 

Which  way  does  the  face  turn,  after  it  has  escaped 
the  vulva  ?     To  the  inside  of  the  right  thigh. 

Does  the  forehead  present  any  difficulty  in  its  pas- 
sage under  the  arch  ?  It  is  believed  by  some  that  it 
escapes  less  readily  than  the  occiput,  though  it  pro- 
bably does  not,  if  the  coccyx  and  perinaeum  offer  no 
resistance. 

Which  is  the  most  rare  position  of  all  the  occipital 
presentations?     The  sixth. 

Why  does  it  occur  rarely?  Because  of  the  ex- 
treme difficulty  of  having  two  rounded  surfaces,  like 
the  occiput  and  promontory  of  the  sacrum  kept  in 
contact  with  each  other. 

What  is  the  mechanism  of  labor  in  the  sixth  posi- 
tion ?     The  head  is   driven  directly  down  the  central 


142  PREGNANCY — LABOR. 

line  of  the  sacrum  without  any  rotation.  The  shoul- 
ders are  rotated  as  in  the  third  position,  except  that 
they  are  reversed. 

POINTS  PARTICULARLY  TO  BE  STUDIED. 
Wliat  are  the  two  main  points  to  be  studied,  in 
reference  to  the  mechanism  of  all  the  positions  ?  The 
characteristics  of  the  first  and  the  fourth  positions, 
as  containing  the  elements  of  the  mechanism  in  all 
the  other  varieties. 

ADDITIONAL  POSITIONS. 
Are  there  no  other  positions  of  the  occiput  worthy 
to  be  Tjmbraced  in  a  systematic  classification  by  au- 
thors or  teachers  ?  There  are  two  others,  viz. : — one, 
in  which  the  occiput  is  directed  towards  the  left  side 
of  the  superior  strait  which  terminates  the  transverse 
diameter,  and  the  other,  in  which  the  occiput  is  di- 
rected exactly  towards  the  other  or  right  extremity 
of  that  diameter — in  other  words,  they  might  be  des- 
cribed as  occipito-left  iliac  or  seventh  position,  and  oc- 
cipito-right  iliac  or  eighth  position.  They  are  some- 
times called  transverse  positions. 

CONVERTIBILITY  OF  THE  POSITIONS. 

Why  are  the  two  transverse  positions  of  the  head 
at  the  superior  strait  easily  convertible  into  the  first 
or  second,  fourth  or  fifth  ?  Owing  to  the  facility  of 
the  rotation  of  the  head  upon  the  inclined  planes. 

Why  may  the  fifth  position  become  converted  into 
the  first,  and  the  fourth  into  the  second  ?  Owing  to 
the  fact  that  the  anterior  inclined  planes  are  larger 
than  the  posterior  inclined  planes. 

MOVEMENTS  EXECUTED  ON  THE  SHOULDERS. 
What  changes  do  the  shoulders  undergo  as  they  are 
forced  through  the  pelvis  in  a  first  position  of  the  ce- 
phalic extremity  ?  The  right  shoulder  being  already 
at  the  commencement  of  the  labor  in  the  right  side 
of  the  pelvis,  in  advance  of  the  transverse  diameter,  is 


PREGNANCY — LABOR.  143 

under  the  influence  of  the  contractions  of  the  uterus 
and  the  spiral  form  of  the  pelvis,  forced  to  slide  along 
the  right  anterior  or  ischio  pubic  plane  till  it  is  ap- 
plied behind  the  symphysis  or  under  the  arch  of  the 
pubes.  The  left  shoulder  being  behind  the  transverse 
diameter  on  the  left  side  of  the  pelvis,  is  likewise  car- 
ried down  by  the  uterine  forces  acting  on  the  body  of 
the  fetus,  and  partly  by  the  spirality  of  the  materials 
filling  up  the  ischio-sacral  notch,  but  especially,  per- 
haps, by  the  influence  of  the  right  anterior  inclined 
plane  upon  the  opposite  shoulder,  it  is  obliged  to  ap- 
pear upon  the  median  line  of  the  sacrum  and  coccyx, 
over  which  it  is  made  to  pass  by  the  continued  uterine 
and  abdominal  forces. 

How  do  the  shoulders  rotate  in  the  second  position 
of  the  occiput  ?  The  left  shoulder  is  carried  down  on 
the  left  anterior  inclined  plane,  and  becomes,  at  the 
inferior  strait,  the  pubal  shoulder,  while  the  right  one 
is  carried  along  the  right  posterior  inclined  plane  and 
becomes  the  sacral  shoulder. 

How  are  the  shoulders  disposed  of  in  the  third  or 
occipito-pubal  position  ?  Either  shoulder  may  engage 
on  the  right  or  left  anterior  inclined  plane,  and  so 
be  made  to  appear  under  the  arch  of  the  pubes. 

What  becomes  of  the  shoulders  in  the  fourth  cepha- 
lic position  ?  The  left  one  being  upon  the  right  an- 
terior inclined  plane  is  carried  downward  and  forward 
by  the  uterine  and  abdominal  forces  till  it  is  brought 
behind  or  under  the  symphysis  of  the  pubes,  while 
the  right  shoulder  is  necessarily  moved  downward 
and  backward  on  the  left  posterior  inclined  plane 
to  appear  at  length  at  the  posterior  commissure  of  the 
vulva. 

What  may  be  said  of  the  rotation  of  the  shoulders  in 
the  fifth  position  of  the  cephalic  presentation  ?  That 
here  of  course  the  right  shoulder  is  compelled  to  de- 
scend along  the  left  anterior,  and  the  left  on  the  right 
posterior  inclined  plane,  till  they  each  appear  at  the 
vulva. 


144  LABOE— ARRANGEMENT    OF  THE    BEl). 

Is  there  any  known  law  by  which  to  determine 
which  of  the  two  shoulders  shall  descend  on  the  right 
or  left  anterior  plane,  and  the  sixth  or  occipito-sacral 
position  of  the  head  ?  As  in  the  third  position,  we 
have  here  no  reason  why  one  shoulder  in  preference 
to  the  other  should  descend  upon  the  one  or  the  other 
of  the  anterior,  or  on  the  opposite  posterior  inclined 
plane  of  the  pelvis,  consequently,  we  cannot  in  either  the 
third  or  the  sixth  position,  anticipate  to  which  tuber 
ischii  the  occiput  will  necessarily  be  directed,  nor  how 
the  shoulders  will  descend. 

Are  the  rules  which  have  been  stated  as  to  the  man- 
ner in  which  rotation  of  the  shoulders  usually  takes 
place  in  the  oblique  positions  of  the  head  uniform 
and  without  exceptions  ?  No — for  it  has  been  observed 
that  in  some  instances  in  which  the  process  of  the  la- 
bor has  not  been  interfered  with,  the  shoulders  have 
been  found  not  to  rotate  at  all,  or  the  right  shoulder 
has  passed  down  on  the  plane  different  from  that  on 
which  it  would  have  been  expected  to  rotate,  and  even 
in  a  few  instances  in  which  the  occiput  of  the  child 
had  appeared  at  the  arch  of  the  pubes,  the  centre  of 
the  fetal  dorsum  has  been  forced  to  slide  along  the 
median  line  of  the  coccyx  and  perinseum. 

How  are  the  hips  arnd  the  lower  extremities  usually 
disposed  of  in  their  descent  through  the  pelvis  ?  In  some 
cases  the  hips  obey  the  same  law  of  rotation,  as  the 
slioulders,  though  this  is  not  uniformly  observed.  The 
lower  extremities  are  almost  always  unfolded,  and 
extended  before  they  pass  through  the  canal  and  ap- 
pear at  the  vulva. 

ARRANGEMENTS  OF  THE  CHAMBER  AND  BED  OF  THE 
ACCOUCHEE. 

What  kind  of  room  should  the  patient  select  for 
her  nursery  during  her  parturient  and  puerperal  state  ? 
It  should  be  spacious  and  well  ventilated,  so  circum- 
stanced that  light  and  noise  can  be  excluded  when 
necessary. 


LABOR — ARRANGEMEXT    OF   THE   BED.  145 

What  arrangement  should  be  made  in  reference  to 
the  bed  ?  It  should  be  so  situated  as  to  be  accessible 
if  possible  at  each  side  and  the  foot.  It  should  have 
posts  sufficiently  high  to  enable  her  to  place  her  feet 
against  either  one  as  may  be  desired,  and  if  there  be 
curtains,  these  should  be  kept  so  drawn  up  that  the  bed 
may  be  well  ventilated. 

What  objection  to  her  being  delivered  on  one  bed, 
and  after  labor  transferred  to  another  ?  There  is 
often  much  inconvenience  as  well  as  hazard  in  making 
the  transfer,  as  hemorrhage,  &c.  might  be  thus  brought 
on. 

How  should  you  have  the  bed  prepared  for  de- 
livery ?  First,  have  the  bed,  if  of  feathers,  properly 
flattened  down,  then  place  upon  the  middle  portion 
of  it  upon  which  the  hips  will  rest  after  delivery,  a 
folded  sheet,  blanket,  or  any  soft  material  to  protect 
the  bed  below  from  the  lochia,  which  may  escape  from 
beyond  its  immediate  recipients.  Then  place  on  the 
lower  sheet  or  blanket,  fold  the  lower  end  of  this  in 
sever'al  short  folds  so  near  the  middle  of  the  bed,  that 
"when  the  patient  is  placed  in  her  proper  situation 
after  delivery,  this  fold  will  be  below  her  hips.  Put 
on  the  top  of  this  sheet,  directly  over  the  doublings 
beneath  it,  a  few  folds  of  soft,  CMiifortable  material, 
on  which  the  hips  will  rest  when  the  patient  is  placed 
up  in  bed  after  delivery,  and  w^hich  being  more  easily 
removed  than  the  expanded  sheet,  may  serve  well  to 
receive  any  discharges  which  may  escape  beyond  the 
perin?eal  napkin.  Place  upon  the  lower  portion  of  the 
bed,  first  an  oil-cloth,  or  some  other  impervious  mate- 
rial, and  over  this,  several  folds  of  clothing,  as  blan- 
kets, sheets,  or  something  of  this  kind,  so  arranged  as 
to  cover  principally,  or  entirely,  the  portion  of  the 
bed  thus  left  bare  by  the  folding  up  of  the  lower 
sheet.  Bring  the  lower  edge  of  these  folds  a  little 
over  the  foot  or  edge  of  the  bed,  at  which  the  accou- 
cheur is  to  sit.  Then  place  the  pillows  diagonally 
across  the  bed,  that  they  will  be  comfortablv  under 
18 


146  LABOR — ARRANGEMENT    OF    PATIENT. 

the  patient's  head  when  she  is  sufficiently  flexed. 
Replace  the  bed-covers,as  sheet,  blanket  and  spread, 
comfortable,  or  quilt,  as  the  case  may  be,  as  though 
the  bed  had  been  made  up  as  ordinarily ;  then  fold 
the  upper  cover  back  to  the  farther  side  of  the  bed 
from  which  the  patient  will  lay  while  in  labor,  back 
over  this  fold  the  free  edge  of  the  next  cover,  and  so 
on  till  the  last  free  sheet  is  disposed  of  in  the  same 
way.  To  that  bed  post  against  which  her  feet  are  to 
be  fixed  when  she  is  placed  on  the  bed,  attach  a  towel 
or  strong  band,  in  such  manner  that  her  hand  may 
embrace  the  loop  of  it  when  she  is  properly  flexed. 
It  is  even  better  to  pass  a  short  round  stick  through 
the  loop  so  made,  that  the  patient  may  make  equal 
draughts  with  both  her  hands  during  a  strong  bear- 
ing down  pain. 

What  principal  object  should  the  physician  have  in 
view  in  giving  directions  for  the  preparations  of  the 
bed  ?  That  the  patient  may  lie  upon  her  left  side  so 
curved  forward  as  to  throw  the  axis  of  the  body  into 
nearly  the  same  line  with  that  of  the  uterus. 

How  should  the  patient  be  prepared  to  be  placed  on 
the  bed  ?  Her  body  clothing  should  be  so  adjusted 
that  she  need  not  have  it  all  soiled.  For  this  reason 
her  skirts  should  be  laid  aside ;  her  linen  so  folded  up 
around  her  waist  that  it  will  be  beyond  the  risk  of 
discharges,  a  bandage  suitable  for  encircling  her  ab- 
domen after  delivery,  should  be  placed  around  her 
waist,  and  so  pinned  as  to  retain  her  linen  as  folded 
up ;  and  next  a  sheet  or  blanket  should  be  folded  in 
double  in  the  direction  of  its  length,  the  thin  edges  of 
this  fold  should  be  placed  in  front  of  the  abdomen, 
and  carried  round  on  each  side  to  the  middle  of  the 
back,  or  better  still,  one  portion  should  be  carried 
round  the  left  side  over  the  back,  to  meet  the  other 
portion  on  the  right  side,  where  it  should  be  carefully 
pinned  with  a  large  pin,  taking  care  to  have  the  por- 
tion of  the  sheet  or  blanket  carried  round  the  body, 
so  adjusted  that  the  portion  which  is  carried  round  the 


LABOR— ARRANGEMENT    OF    PATIENT.  147 

riglit  side  will  extend  at  least  twice  as  far  backward  as 
that  on  the  left.  The  night  or  bed  gown,  which  should 
be  a  short  one,  can  then  be  allowed  to  drop  down  from 
the  shoulders  to  the  waist.  The  patient  should  have 
stockings  on,  without  any  garters  to  retard  the  circula- 
tion, her  feet  should  mostly  also  be  protected  by  slippers. 
She  should  then,  if  the  stage  of  her  labor  require,  be 
placed  upon  her  left  side,  with  her  hips  within  a  foot 
of  the  lower  end  of  the  bed,  her  body  flexed  forward, 
her  lower  extremities  drawn  up,  that  her  feet  may  be 
placed  against  the  right  foot  post  of  the  bed  ;  the 
lower  side  of  the  sheet  or  blanket  is  then  to  be 
drawn  out  smoothly  under  her,  while  the  upper  por- 
tion is  to  be  carried  out  also  smoothly  behind  her ;  it 
will  thus  protect  her  completely  from  any  exposure 
of  her  person ;  next  over  this  may  be  drawn  a  suit- 
able amount  of  bed  clothes. 

Is  it  important  what  kind  of  bandage  the  patient 
should  have  prepared  for  her  use  immediately  after 
parturition  ?  Notwithstanding  the  diversity  of  opinion 
and  practice  amongst  physicians  on  this  point,  and 
the  great  variety  of  form  and  mode  of  application  of 
this  essential  article  by  women,  it  is  unquestionably 
important,  that  the  principle  to  be  kept  in  view  in  the 
use  of  the  bandage,*  is  that  it  gives  support  to  the  up- 
per portion  of  the  thighs,  the  entire  pelvic,  and  the 
greater  portion  if  not  the  whole  of  the  lumbar,  and 
abdominal  regions  of  the  body. 

What  form  of  bandage  is  best,  to  fulfil  this  indica- 
tion ?  It  should  be  made  to  fit  exactly  the  curve  or 
hollow  of  the  back,  spread  out  neatly  over  the  nates, 
then  be  so  contracted  below  as  to  be  exactly  adapted 
to  the  back  part  of  the  upper  portion  of  the  thighs, 
with  the  extremities  long  enough  to  overlap  each  other 
a  few  inches  in  front  of  the  person,  where  it  may  be 
smoothly  secured  by  strong  pins  or  laced  by  a  large 
needle  armed  by  thread  of  sufficient  size  and  strength 
to  make  the   requisite  compression  upon  the  several 


148   LABOR — ARRANGEMENT  FOR  THE  CHILD. 

points  from  just  below  the  pubes  to  the  scrobiculia 
cordis,  or  the  lower  margin  of  the  mammae. 

How  can  a  bandage  so  constructed  be  placed  around 
the  waist  of  the  patient,  in  such  manner  that  it  can  be 
gotten  down  to  its  place  after  delivery  without  incon- 
venience to  the  patient,  nurse,  or  accoucheur  ?  Let 
the  nurse  or  temporary  attendant  upon  the  patient  ex- 
tend this  bandage  upon  a  bed,  fold  it  in  three  plaits 
or  folds,  of  which  the  lower  edge  shall  be  the  first,  the 
middle  of  the  bandage  shall  be  the  second,  and  the 
upper  margin  shall  be  the  last  or  uppermost  plait  ; 
this  will  reduce  the  plaited  bandage  to  about  the  width 
of  her  hand  and  extended  thumb.  Let  her  then  plait 
it  in  short  plaits  in  the  opposite  direction,  crosswise, 
or  at  right  angles  with  the  longitudinal  folds  ;  the 
whole  bandage  thus  folded  up  she  can  now  take  in 
one  hand  and  carry  it  around  the  waist  of  the  patient, 
(so  as  to  embrace  the  folds  of  the  chemise  previously 
adjusted,)  till  it  can  be  met  by  the  opposite  hand;  the 
two  ends  are  next  to  be  brought  round  upon  the  mass 
of  folds  of  the  under  garment,  and  when  it  is  properly 
secured  by  a  single  large  pin  it  will  be  found  to  retain 
this  part  of  the  under  dress  completely  above  all  or- 
dinary risk  of  becoming  soiled  by  the  fluids  which  may 
escape  from  the  uterus  in  the  progress  of  the  labor. 

What  is  next  to  be  done  to  cover  the  lower  extrem- 
ities of  the  patient  while  in  labor  ?  Adjust  the  sheet 
outside  of  this  as  explained  in  the  answer  to  the  ques- 
tion about  preparing  the  patient  for  placing  her  on 
the  bed. 

What  provision  should  be  made  in  reference  to  the 
management  of  the  child  at  its  birth  ?  There  should 
be  provided  a  proper  ligature  for  the  umbilical  cord, — 
a  pair  of  sharp-edged,  but  blunt  ended  scissors,  should 
be  at  hand  ;  also  suitable  clothing,  in  which  to  envelope 
the  child  when  born.  There  should  also  be  the  means 
at  command  of  raising  the  temperature  if  necessary — 
as  for  example,  an  abundant  supply  of  warm  water, 
and  also  some  suitable   stimulants,  as  spirits,  aq.  am- 


LABOR — ACCOMMODATION    FOR    ACCOUCHEUR.     149 

monise,  or  something  of  the  kind,  to  excite  respiration 
if  necessary. 

What  accommodation  should  be  furnished  the  ac- 
coucheur ?  A  chair  to  sit  upon,  some  unctuous  mat- 
ter with  which  to  lubricate  his  hand,  and  the  soft  parts 
of  the  mother ;  and  several  napkins,  properly  plaited 
or  folded,  for  use  as  required. 

What  course  of  conduct  should  the  accoucheur  ex- 
ercise while  in  attendance  upon  the  parturient  female  ? 
It  should  be  such  as  would  preserve  her  feelings  free, 
and  inspire  her  with  proper  confidence  in  him — he 
should  remain  calm  under  all  circumstances,  carefully 
avoid,  by  any  action  or  change  of  countenance,  excit- 
ing her  apprehensions  of  an  unfavorable  termination 
of  her  case ;  he  should  offer  candidly  all  reasonable 
prospects  of  a  happy  and  safe  delivery,  though  he 
should  cautiously  avoid  any  promise  as  to  this  or  the 
time  of  its  occurrence.  He  should  suppress  all  un- 
necessary talking,  or  allusions  to  any  other  cases  which 
may  have  been  knoAvn,  or  reported  to  be  fatal  or  haz- 
ardous ;  he  should  advise  his  patient  against  straining, 
or  forcibly  bearing  down  during  the  first  stage,  but 
strongly  urge  the  necessity  of  it,  during  the  second 
stage.  He  should  carefully  ascertain  the  state  of  the 
bladder  and  bowels,  and  direct  accordingly ;  he  should 
recommend  his  patient  to  remain  up  considerably, 
during  the  first  stage,  but  to  lie  down,  during  the  re- 
maining period  of  labor.  He  should  not  remain  con- 
stantly with  her  during  the  first  stage,  but  not  be  ab- 
sent from  her  subsequently  until  the  whole  process  is 
completed. 

What  accommodation  should  be  supplied  to  the  ac- 
coucheur, w^hen  he  is  about  to  make  an  examination, 
or  is  preparing  to  assist  the  patient  by  receiving  her 
child,  &c.  ?  The  nurse  should  adjust  a  napkin  around 
each  fore  arm,  if  he  wish  it,  place  a  sheet,  or  folded 
cloth  upon  his  lap,  put  within  his  reach  several  nap- 
kins, diapers  or  cloths,  and  a  cup  of  lard  or  pure  oil. 
13* 


150  LABOR — MODE    OF   EXAMINATION. 

She  should   do   this   quietly,  and   he  should  take  his 
seat  with  as  little  parade  as  possible. 

Thus  seated,  and  otherwise  accommodated,  what 
should  he  proceed  to  do  ?  To  make  a  proper  examin- 
ation, to  determine  the  exact  state  of  the  case  if 
possible. 

PHYSICAL  ENQUIRY  INTO  THE  FACT  OR  PROGRESS  OF 
LABOR— PATIENT  RECLINING. 

How  should  he  make  this  examination  ?  He  should 
be  seated  with  his  right  side  to  the  bed ;  the  nurse,  or  he 
with  his  left  hand,  should  slightly  and  cautiously  elevate 
the  double  fold  of  the  sheet,  which  had  been  placed 
around  the  patient  before  she  was  laid  on  the  bed  ; 
when  a  pain  occurs,  he  should  lubricate  the  index 
finger  of  the  right  hand,  and  keeping  this  finger  flexed 
towards  the  hollow  of  the  hand,  at  the  same  time  that 
the  thumb  is  strongly  extended,  (thus  guarding  the 
finger,  from  the  risk  of  having  the  ointment  on  it 
rubbed  off  on  the  clothes,  and  subsequently  perhaps, 
smeared  upon  his  coat  sleeve,)  he  should  pass  his  right 
hand  under  the  folds  of  the  sheet,  the  double  of  which 
had  been  slightly  raised  by  his  left  hand,  or  by  the 
nurse.  The  left  hand  is  then  to  be  carried,  exterior 
to  all  the  covers,  to  the  region  of  the  right  trochanter  ; 
at  the  same  time,  the  right  hand  glided  along,  under 
the  folds"  of  the  sheet  in  the  manner  directed,  is  to  be 
passed  a  little  posterior  to  the  spot  upon  which  the 
left  hand  slightly  rests,  viz. :  upon  the  right  trochanter; 
in  this  way  the  knuckle  of  the  examining  finger  may 
with  considerable  certainty  be  brought  to  the  sulcus 
between  nates,  or  to  the  raphe  of  the  perinBeum,  and 
then  glided  forwards,  until  it  slips  into  the  genital  fis- 
sure over  the  posterior  commissure,  without  bringing 
it  in  contact  with  the  sensitive  apparatus  at  the  ante- 
rior commissure  ;  when  once  the  finger  has  gained  this 
aperture,  it  may  be  extended  along  the  vagina,  with 
its  ulnar  edge  towards  the  arch  of  the  pubes,  and  thus 
cautiously  applied  to  the  orifice  of  the  uterus,  &c. 


LABOR — MODE    OF    EXAMINATION. 


151 


Although  it  is  mostly  greatly  preferable  that  the 
patient  should  be  upon  her  left  side  for  examination, 
or  for  labor,  is  it  not  embarrassing  to  the  accoucheur 
to  make  the  touch  or  rupture  the  membranes  by  the 
finger  applied  to  the  orifice  of  the  uterus  as  usually  di- 
rected? The  usual  mode  of  applying  the  finger  to 
the  orifice  of  the  womb,  with  its  ulnar  edge  to  the 
pubes  does  not  permit  the  finger  readily  either  to  re- 
cognise the  condition  of  the  orifice  of  the  uterus,  the 
character  of  the  presentation,  nor  to  rupture  the  mem- 
branes, as  may  be  seen  in  fig.  66, 

Fig.  66. 


How  may  this  difliculty  be  obviated?  By  changing 
the  direction  of  the  hand  after  the  finger  is  inserted, 
BO  Hhat  by  forced  supination,  or  better  still,  by  forced 
pronation,  which  is  accommodated  by  a  degree  of  cor- 
responding motion  in  the  arm  and  body  of  the  accou- 


152 


LABOR — MODE    OF   EXAMINATION. 


cheur,  the  pulp  of  the  right  index  finger  can  be 
brought  much  more  eifectivelj  into  relation  with  the 
parts  than  when  confined  to  the  ulno-pubal  position. 


What  is  the  importance  of  making  this  examination 
at  the  time  of  a  pain  ?  First,  that  he  may  determine 
whether  she  is  really  in  labor  or  not,  and  next  to  as- 
certain the  degree  of  dilatation  of  the  os  uteri,  and  if 
possible  the  presentation  of  the  child. 

ADVANTAGES  OF  UPRIGHT  POSITION. 

Is  it  ever  warrantable  to  make  the  examination  of 
the  condition  of  the  os  uteri,  in  the  supposed  incipient 
stage  of  labor,  while  the  patient  is  in  the  erect  position? 
There  are  many  instances  in  which  an  examination  in 
this  manner  would  be  less  inconvenient  to  the  patient 
and  attendants,  and  because  of  the  greater  facility  of 


LABOR — MODE    OF    EXAMINATION.  153 

reaching  the  os  uteri  by  the  proper  curve  of  the  index 
finger,  more  accurate  diagnosis  of  the  condition  of  the 
OS  uteri  and  the  impression  of  a  contraction  upon  it 
may  be  obtained,  than  when  the  patient  is  in  the  hor- 
izontal position  on  her  left  side. 

TIME  AND  MANNER— PATIENT  STANDING. 

What  are  the  proper  time  and  manner  of  making 
the  examination  by  touch  in  this  way  ?  With  a  proper 
understanding  of  the  greater  advantage  and  facility 
of  this  method,  provided  the  patient  has  not  been  al- 
ready prepared  to  lay  upon  the  bed  for  her  delivery, 
and  under  the  impression  also  from  the  character  of 
the  pains  that  the  labor  has  not  yet  so  far  advanced 
as  not  to  admit  of  her  remaining  up  for  some  time 
longer,  let  the  nurse  or  temporary  female  attendant 
quietly  provide  the  proper  napkin  and  lard  or  oil,  and 
place  them  within  easy  reach  of  the  physician.  Let 
her  next  take  her  position  by  the  left  side  of  the  pa- 
tient as  she  sits,  and  when  a  pain  occurs  let  the  patient 
rise  by  the  side  of  the  nurse  and  repose  slightly  upon 
her,  w^hile  the  latter  stooping  forwards,  gently  collects 
the  lower  margin  of  all  the  patient's  skirts,  carries 
them  forward  and  but  very  little  upwards  until 
they  can  be  deposited  upon  the  flexure  of  the  phy- 
sician's arm  as  he  is  proceeding  to  make  the 
enquiry  by  examination.  She  will  thus  act  in  the 
double  capacity  of  companion  and  assistant  to  the  pa- 
tient. 

What  should  be  the  movements  of  the  accoucheur 
in  making  the  examination  in  this  way  ?  Having  pru- 
dently seated  himself  near  the  right  side  of  the  patient, 
and  with  his  right  hand  nearest  to  her,  let  him,  upon 
the  intimation  that  she  has  a  pain  and  is  about  rising 
by  the  side  of  the  nurse,  anoint  his  finger,  cast  the 
napkin  loosely  over  his  wrist,  carry  his  left  hand  over 
the  right  hip  to  the  sacrum  or  loins  of  the  patient  to 
assist  in  giving  her  moderate  support  while  the  right 
hand  (the  index  finger   of  which  is  properly  guarded 


154      LABOR — DUTIES  OF  PHYSICIAN  AND  NURSE. 

against  the  risk  of  having  the  lubricating  matter  rubbed 
off  it)  is  carried  upwards  under  the  dress  of  the  patient 
to  the  raphe  of  the  perinosum  or  posterior  commissure 
of  the  vulva,  from  which  its  introduction  into  the  va- 
gina can  usually  be  easily  effected  without  distress  to 
the  patient  or  embarrassment  to  himself,  the  os  uteri 
easily  reached,  and  its  condition  mostly  made  out  with 
much  precision. 

How  much  time  is  allowed  for  this  examination  in 
the  erect  position  ?  Only  so  much  as  is  occupied  by  a 
pain  or  uterine  contraction. 

WHEN  TO  BE  PUT  TO  BED  FOR  THE  COMPLETION  OF 
LABOR. 

When  should  she  be  put  to  led  for  the  completion 
of  labor  ?  When  you  believe  the  os  uteri  is  nearly  or 
entirely  dilated,  as  shewn  in  fig.  68. 


Fig.  68. 


DUTIES  OF  PHYSICIAN,  NURSE,  AND  PATIENT  DURING 
^  THE  SECOND  STAGE  OF  LABOR. 

Why  should  you  have  her  flexed  forward  ?  That 
the  axis  of  her  uterus  may  be  thrown  into  a  line  with 
the  axis  of  the  superior  strait. 

Is  it  easy  for  you  always  to  determine  the  Presen- 
tation of  the  child,  previous  to  the  rupture  of  the  mem- 


LABOR — DUTIES  OF  PHYSICTAX  AND  NURSE.      155 

branes?  It  is  mostly  easy  to  do  so,  unless  it  be  a 
presentation  of  the  face,  side,  or  back,  or  breech  of 
the  child. 

Is  the  Position  easy  to  be  recognised  through  the 
membranes  ?  In  general  it  is  not,  until  after  they  are 
ruptured,  and  the  presenting  part  fairly  engaged  in 
the  pelvis. 

Does  labor  usually  proceed  more  rapidly  after  the 
rupture  of  membranes,  if  the  os  uteri  be  properly  di- 
lated ?  It  does,  perhaps  in  consequence  of  the  short- 
ening of  the  muscular  fibres  of  the  uterus,  and  their 
contact  with  the  firmer  and  less  regular  surface  of  the 
fetus. 

How  should  you  rupture  the  membranes  ?  By  press- 
ing the  point  of  the  finger  into  the  fold  of  the  mem- 
branes, if  the  bag  of  water  be  large ;  if  not  promi- 
nent, the  nail  of  the  finger  should  be  directed  towards 
the  presenting  part  of  the  child,  and  then  by  a  little 
vibratory  motion  gradually  wear  them  away.  This 
must  be  done  with  great  caution,  lest  the  scalp  should 
be  torn  in  the  process. 

Should  you  use  any  precautions  for  your  protection 
from  the  sudden  escape  of  the  liquor  amnii,  when 
you  open  the  membranes  ?  The  wrist  should  be  en- 
veloped in  a  napkin,  and  one  should  also  be  applied 
to  the  perinceum  and  vulva,  so  that  at  the  instant  you 
burst  the  membranes,  you  may  withdraw  the  finger, 
and  apply  the  napkin  to  absorb  the  discharge. 

Should  you  change  the  saturated  napkins  privately  ? 
They  should  be  either  handed  quietly  to  the  nurse,  or 
laid  secretly  at  the  bottom  of  the  bed-post  without 
calling  aloud  to  any  one  about  them. 

Should  you  after  this  time  keep  any  thing  applied 
to  the  breech  of  the  patient  to  absorb  the  discharges  ? 
This  should  be  done  by  applying  successively  folds  of  a 
sheet,  or  better  still,  by  changing  napkins  as  fast  as 
they  become  saturated.  By  this  plan,  the  patient  is 
rendered  less  uncomfortable  and  the  bed  less  soiled. 

If  the  membranes  require  to  be  ruptured  artificially 


156     LABOR — DUTIES    OF  PHYSICIAN    AND    NURSE. 

at  what  period  of  the  pain  should  it  be  done  ?  At  the 
commencement  if  possible. 

Should  the  accoucheur  interfere  with  the  process  of 
labor,  during  the  second  stage  ?  He  should  let  it 
alone,  if  he  have  ascertained  that  the  position  is  cor- 
rect. 

When  should  the  patient  be  encouraged  to  assist  the 
expulsive  effort  ?  As  soon  as  the  os  uteri  is  dilated, 
and  the  first  stage  complete. 

If  she  do  not  know  how,  what  instructions  should 
you  give  her  ?  To  take  in  a  full  breath,  and  bear 
down  the  whole  time  of  a  pain ; — to  bend  herself  for- 
Avard,  &c. 

How  can  she  bring  her  accessory  powers  most  ad- 
vantageously to  co-operate  with  the  pains  or  relieve 
contractions  during  the  second  stage  of  the  labor  ?  In 
by  far  the  greatest  number  of  cases  the  efficiency  of 
the  accessory  aid  is  increased  by  giving  the  patient  a 
firm  purchase  with  her  feet  against  the  post  of  the 
bed,  or  some  other  immoveable  point,  while  her  ex- 
tended arms  may  reach  the  same  point  by  means  of 
a  well  adjusted  cord,  napkin  or  any  similar  medium, 
with  a  little  round  short  stick  passed  through  the  loop 
of  it,  so  that  she  can  flex  the  fingers  of  a  hand  on 
each  side  of  the  tow^el  or  cord,  without  the  risk  of 
contusing  them  by  irregular  pressure  during  her  bear- 
ing down  effort. 

Should  she  be  careful  to  relax  herself,  as  soon  a  a 
the  pain  is  off?  This  should  be  insisted  upon  in  most 
cases. 

What  kind  of  drink  or  other  comforts  should  she 
have  to  revive  her  during  the  second  stage  ?  Cool 
water,  lemonade,  toast  water,  carbonated  or  mineral 
water,  gentle  fanning  and  such  changes  in  the  thick- 
ness of  her  covers  as  her  condition  may  require. 

When  should  the  nurse  adjust  a  large  cushion  or 
rolled  up    pillow  between  the    limbs   of  the   patient  ? 

When  the  accoucheur  has  observed  that  the  present- 
ing part  of  the  child  presses  on  the  perinneum. 


LABOR — DUTIES  OF  PHYSICIAN  AND  NURSE.     157 

In  what  direction  should  the  pillow  be  placed  ? 
Prom  ancle  to  knee,  so  as  to  be  exactly  longitudinally 
above  the  left,  and  below  the  right  leg. 

What  is  the  proportionate  force  of  the  uterine  con- 
tractions, during  the  labor  ?  Inversely  as  the  size  of 
the  organ,  according  to  the  calculations  of  some  obstet- 
ricians. ' 

When  is  the  force  of  the  contractions  of  the  uterus 
at  its  acme  ?  When  the  presenting  part  is  about  to 
pass  through  the  genital  fissure. 

Is  there  any  danger  of  rupture  of  the  perinseum  in 
most  cases  of « labor  ?  It  has  been  known  to  rupture 
during  the  progress  of  natural  labor. 

How  must  the  perinseum  be  supported  ?  It  is  best 
done  by  the  accoucheur,  applying  the  palm  of  his  hand 
over  the  perinseum,  and  keeping  his  wrist  directed  to- 
wards the  child's  head. 

What  should  be  interposed  between  the  hand  and 
perinseum  ?  A  napkin  which  will  receive  the  feces  if 
any  escape. 

In  what  direction  may  the  perinseum  be  ruptured  or 
lacerated  ?  From  the  fourchette  backwards  ;  through 
the  centre  ;  or  at  the  anus. 

Is  it  ever  necessary  to  resist  the  descent  of  the 
child,  when  the  perinseum  is  in  danger  ?  It  is,  if  the 
perinseum  is  not  relaxed. 

When  is  the  greatest  danger  of  laceration  ?  At  the 
moment  that  the  parietal  protuberances  are  passing 
through  the  vulva. 

WHAT  TO  DO  WHEN  THE  HEAD   HAS  PASSED    THROUGH 
THE  VULVA. 

When  the  head  escapes,  what  attention  should  be 
given  in  reference  to  the  child  ?  To  ascertain  whether 
the  cord  is  around  the  child's  neck,  and  if  so,  to  at- 
tempt to  loosen  it  by  drawing  gently  upon  one  ex- 
tremity of  it. 

Suppose  the  cord  to  encircle  the  neck  so  closely  as 
to  interfere  with  respiration  or  the  quick  descent  of 
14 


158     LABOii — DUTIES    OF  PHYSICIAN   AND    NURSE. 

the  child,  what  should  you  do  then  ?  Carefully  divide 
it,  and  then  expedite  the  delivery  by  traction  by  the 
head  and  neck  of  the  child. 

Should  the  head  of  the  child  be  supported  after  its 
extrusion  ?  It  should  repose  in  an  expanded  hand  of 
the  accoucheur. 

What  attention  should  be  given  to  the  shoulders,  if 
they  do  not  readily  rotate  ?  Assist  the  rotation  by 
pressing  the  proper  one  under  the  arch  and  lihe  other 
into  the  hollow  of  the  sacrum. 

Under  what  circumstances  may  the  accoucheur 
draw  a  little  upon  the  head  ?  When  the  perinseum 
offers  a  strong  resistance  to  the  exit  of  the  shoulders. 

In  what  direction  should  he  draw  upon  the  head  ? 
If  a  shoulder  be  thrown  up  behind  the  symphysis  pu- 
bes,  the  traction  should  be  towards  the  sacrum,  suffi- 
cient to  disengage  the  pubal  shoulder  ;  but  if  this  be 
already  free,  the  traction  may  be  made  in  the  direc- 
tion of  the  axis  of  the  vagina. 

Having  cleared  the  shoulders  from  the  grasp  of  the 
perinseum,  should  you  hasten  the  delivery  of  the  rest 
of  the  child  ?  No  ;  its  delivery  should  be  rather  re- 
tarded, in  order  to  allow  the  uterus  to  contract  well 
upon  it  and  the  placenta. 

What  should  you  do  as  soon  as  the  body  is  ex- 
truded ?  Carry  the  child  round  and  place  it  in  such 
a  position  as  to  be  free  from  the  discharges  of  the 
mother. 

What  attention  should  you  give  the  mother  as  soon 
as  the  child  is  born  ?  Calm  her  excitement  and  ascer- 
tain that  the  uterus  is  contracted. 

How  should  you  do  this  ?  Speak  kindly  and  sooth- 
ingly to  her  ;  then  place  your  hand  on  the  abdomen 
and  feel  what  the  condition  of  the  uterus  is — if  it  do 
not  contain  another  ovum — make  moderate  compres- 
sion upon  it  to  insure  its  contraction  upon  the  pla- 
centa and  membranes. 


LABOR—DUTIES   OF  PHYSICIAN   AND    NURSE.     159 


TYING  AND  DIVIDING  THE  CORD. 

Is  it  proper  to  put  the  ligature  on,  and  to  cut  the 
cord  immediately  after  the  child  is  extruded  ?  It  is 
better  to  wait  until  respiration,  and  the  capillary  cir- 
culation are  established,  thus  if  the  child  cry,  or  re- 
spire freely,  and  a  red  or  arterial  color  may  be  seen 
on  the  face  and  other  parts  of  the  skin,  the  ligation 
and  division  of  the  cord  may  be  made  with  propriety. 

"What  is  the  obiect  of  applying  a  ligature  upon  the 
cord  ?  To  arrest  the  circulation  in  the  cord,  and 
prevent  hemorrhage  from  its  vessels  when  they  are 
divided. 

How  many  ligatures  should  you  place  upon  the 
cord  ?  One  ligature  only  is  necessary  in  the  great 
majority  of  cases  ;  some  practitioners  think  it  proper 
to  apply  two  ligatures  for  the  purpose  of  cleanliness, 
and  to  avoid  the  possible  risk  of  hemorrhage  in  case 
of  two  placentas  inosculating  with  each  other. 

At  what  distance  from  the  abdomen  should  the  lig- 
ature be  applied  ?     About  two  inches. 

What  precaution  should  you  take  in  relation  to  the 
possibility  of  the  occurrence  of  umbilical  hernia? 
See  that  this  does  not  exist,  or  if  it  does,  apply  the 
ligature  sufficiently  far  beyond  it. 

In  case  you  adopt  the  better  plan  of  putting  only 
one  ligature  upon  the  cord,  what  had  you  best  do  with 
the  extremity  of  the  placental  portion  of  it  ?  Wrap 
it  loosely  in  one  end  or  corner  of  a  napkin  which 
had  been  previously  plaited  transversely  and  laid  upon 
the  right  hip  of  the  patient. 

MODE  OF  RECEIVING  AND  DISPOSING  OF  THE  CHILD. 

In  what  manner  should  you  take  up  the  child  to 
give  it  to  the  nurse }  The  best  plan  is  to  have  a  nap- 
kin so  folded  and  applied  near  the  breech  of  the 
mother,  that  with  one  hand  one  of  its  extremities  can 
be  placed  under  and  support  the  head  as  soon  as  it  is 
extruded ;  as  the  body  passes  out,  these  folds  are  gra- 


160     LABOR — DUTIES   OF  PHYSICIAN   AND    NURSE. 

dually  expanded  until  the  whole  child  is  extended 
upon  it.  Then  as  soon  as  the  cord  is  divided  the 
child  is  to  be  enveloped  in  this  napkin,  and  thus  easily 
lifted  to  the  receptacle  held  by  the  nurse,  for  as  the 
child  is  usually  covered  by  a  very  slippery  or  pasty 
matter,  it  is  often  difficult  or  disagreeable  to  handle  it 
properly.  If,  therefore,  the  napkin  be  not  used,  it 
will  be  found  perhaps  most  convenient  to  pass  the 
palm  of  one  hand  behind  the  thorax  and  nape  of  the 
neck,  while  the  other  is  passed  under  the  thighs,  and 
the  legs  embraced  with  the  index  finger  between 
them.  It  has  been  suggested  as  an  improvement  upon 
this  method,  to  pass  the  palm  of  the  hand  under  the 
thorax,  having  its  radial  edge  towards  the  chin  of  the 
child,  and  thus  raise  it  up  from  the  bed  to  the  receiver 
held  by  the  nurse.  The  child  is  thus  easily  held  by 
the  hand,  and  is  thus  for  a  moment  kept  in  a  position 
nearly  as  much  flexed  as  when  in  utero. 

How  should  the  nurse  receive  and  dispose  of  the 
child  ?  She  should  be  provided  with  a  large  piece  of 
flannel  or  soft  warm  cloth,  which  she  should  present  at 
the  left  side  of  the  accoucheur  :  she  should  then  en- 
velop the  child  and  retain  it  in  her  lap,  or  place  it  in 
some  safe  situation,  till  she  is  prepared  to  wash  and 
dress  it. 

CONDITION  OF  THE  UTERUS  IMMEDIATELY  AFTER  COM- 
PLETION OF  THE  SECOND  STAGE  OF  LABOR. 

Where  may  you  expect  to  find  the  fundus  uteri  after 
the  extraction  of  the  child  ?  Most  frequently  in  the 
umbilical  or  hypogastric  region,  though  occasionally 
it  is  met  with  in  the  left  iliac  fossa. 

Suppose  you  find  the  uterus  firm,  should  you  feel  un- 
easy, however  large  it  may  be  ?  If  it  be  very  firm  and 
somewhere  below  the  umbilicus,  we  perhaps  should 
not  feel  uneasy,  but  if  larger  than  that,  we  should 
suspect  twins,  or  the  presence  of  blood  between  the 
uterus  and  placenta. 


LABOR — DUTIES  OF  PHYSICIAN  AND  NURSE.      161 


MANAGEMENT  OF  THE  PLACENTA. 

Should  the  woman  be  expected  to  deliver  herself 
of  the  placenta  ?  In  the  majority  of  instances  the 
uterus  spontaneously  expels  it  into  the  vagina. 

How  many  pains  does  it  usually  require  ?  Two, 
three,  or  four. 

WHAT  TO  DO  TO  PROMOTE  THE  DELIVERY  OF  THE  PLA- 
CENTA. 

Is  it  ever  necessary  to  stimulate  the  uterus  to  con- 
tract, to  expel  the  placenta  ?  It  is  sometimes  neces- 
sary to  do  so  by  friction.  It  is  always  proper,  and 
often  indispensable  that  the  hand  of  the  accoucheur  or 
nurse  should  be  carefully  applied  over  the  uterine 
tumor  till  the  placenta,  membranes  and  the  coagula, 
if  any,  be  clearly  expelled. 

Should  you  ever  pull  at  the  cord,  unless  you  are 
very  sure  the  uterus  is  well  contracted  ?  Never  more 
than  to  draw  the  cord  into  a  right  line. 

What  danger  attends  the  practice  of  strong  trac- 
tion upon  the  cord  ?  Kupture  of  the  cord,  hemor- 
rhage, inversion  of  the  uterus,  &c. 

Under  what  circumstances  may  you  assist  by  act- 
ing on  the  placenta,  through  the  medium  of  the  cord  ? 
When  the  uterus  has  remained  some  time  torpid  and 
will  not  contract. 

Is  any  rule  of  time  to  be  allowed  for  the  sponta- 
neous delivery  of  the  placenta  ?  Opinions  and  prac- 
tices appear  to  be  very  variable  on  this  point,  though 
it  is  probably  rarely  necessary  to  wait  beyond  twenty 
or  thirty  minutes  after  the  birth  of  the  child. 

In  what  direction  should 'you  act  upon  the  cord,  or 
the  placenta  ?  Always  in  the  axis  of  that  part  of 
the  uterus  or  pelvis  in  which  the  placenta  is  situated. 

How  is  this  to  be  done  ?  By  passing  up  a  finger 
and  allowing  it  to  act  as  a  pulley. 

In  what  direction  when  the  placenta  is  in  the  va- 
gina ?  In  the  axis  of  the  vagina.  In  the  axis  of  the 
14* 


162  DELIVERY — DUTIES   OF   ATTENDANTS. 

inferior  strait,  at  first,  and  afterward  along  the  plane 
of  the  perinaeum. 

Should  you  ever  hook  your  finger  into  the  pla- 
centa, when  it  comes  within  reach  ?  It  may  be  pro- 
per to  do  so  in  case  the  mother  does  not  expel  it 
The  accoucheur  should  always  carry  it  backward  to- 
ward the  sacrum  and  the  perinseum. 

HOW  TO  RECEIVE  AND  DISPOSE  OF  THE  PLACENTA. 

When  you  get  the  placenta  partially  through  the 
vulva  how  should  you  act  upon  it  to  secure  the  deli- 
very of  the  membranes  ?  Retard  its  expulsion  from 
the  vulva  ;  then  rotate  it  upon  its  axis  to  twist  the 
membranes  into  the  form  of  a  cord. 

What  is  probably  the  neatest  and  most  appropriate 
mode  of  receiving  and  disposing  of  the  placenta  when 
delivered  ?  As  it  comes  down  through  the  vulva  let 
the  plaits  of  the  napkin,  which  had  been  placed 
upon  the  right  hip,  under  the  sheet,  be  frequently 
drawn  upon  as  the  mass  is  expelled,  so  that  by  the 
time  the  membranes  and  any  coagula  shall  have  es- 
caped, the  whole  may  be  enveloped  in  the  napkin,  the 
outer  folds  of  which  being  almost  entirely  in  a  dry  con- 
dition, it  can  be  handed  to  the  nurse,  or  any  other 
attendant,  or  laid  quietly  away  by  the  physician 
himself. 

CLEARING  THE    PATIENT  AFTER    COMPLETING  THE    DE- 
LIVERY. 

What  is  meant  by  the  phrase  of  the  lying-in  cham 
ber,  ''  clearing  the  w^oman  ?"  The  complete  removal 
of  the  placenta  with  its  membranes,  and  of  all  the 
coagula  and  other  discharges  which  are  to  be  found 
in  the  vagina  and  about  the  breech  of  the  woman, 
as  well  as  the  application  of  a  soft  dry  napkin  to  the 
vulva. 

What  cautions  should  be  observed  in  reference  to 
the  placing  of  the  woman  in  her  proper  situation  in 
bed  after  delivery  ?     Every  attention  should  first  be 


DELIVERY — DUTIES   OF   ATTENDANTS.  163 

paid  to  "  clearing"  the  woman — a  soft  napkin  should 
be  applied  to  her  vulva — the  bandage  put  properly  over 
the  hypogastric  and  pubic  regions — she  should  then  be 
carefully  slided  up  in  bed,  in  the  completely  horizontal 
position,  without  being  allowed  to  raise  herself  up. 

APPLYING  THE  PERINJEAL  NAPKIN. 

How  can  the  napkin  be  so  applied  as  to  be  kept  in 
gentle  contact  with  the  vulva  to  receive  the  dis- 
charges as  they  escape  from  the  vagina?  Let  one  of 
the  soft  napkins,  at  least  one-third  of  a  yard  wide, 
be  plaited  in  small  plaits,  in  the  direction  of  its  width, 
and  so  adjusted  that  its  middle  portion  will  be  ap- 
plied to  the  vulva,  while  one  extremity  is  carried  for- 
ward upon  the  pubic  region,  where  it  can  be  tem- 
porarily retained,  by  withdrawing  the  pillow  from 
between  the  knees,  and  allowing  the  thighs  to  ap- 
proach each  other  ;  at  the  same  time  the  other  end 
can  be  carried  over  the  perinseum  and  the  sulcus 
between  the  nates  to  the  sacrum,  upon  w^hich  the  ex- 
tremity will  be  expended. 

How  can  it  be  retained  in  this  situation  while  the 
patient  is  subject  to  any  change  of  position,  as  that 
required  for  adjusting  the  pelvic  and  abdominal  band- 
age and  placing  her  up  in  bed?  This  perinseal  nap- 
kin may  be  supported  with  a  temporary  fold  or  two  of 
the  dry  clothing  on  which  she  was  delivered,  so  long  as 
she  remains  on  her  left  side. 

ADJUSTMENT    OF    THE    PELVIC    AND    ABDOMINAL    BAN- 
DAGE. 

What  is  next  to  be  done  ?  While  the  physician  is  en- 
gaged in  making  the  proper  ablution  of  his  hands,  let 
the  nurse  or  some  other  dextrous  attendant  unpin  the 
sheet  which  had  been  placed  around  the  patient,  and 
draw  the  upper  portion  so  far  forward  on  the  pa- 
tient's right  side,  that  it  may  be  quite  loose  ; — directly 
after  this  has  been  done  she  should  unpin  the  band- 
age, and  seizing  the  lower  edge  of  the  upper  of  the 


164  DELIVERY — DUTIES    OF   ATTENDANTS. 

three  folds  in  wliich  it  had  been  arranged,  and  carry 
it  down  on  the  bed,  considerably  below  the  seat  of  the 
patient.  By  this  time  the  physician  or  some  other 
person  whose  care  and  prudence  can  be  relied  upon, 
may  take  hold  of  the  flexed  knees  and  assist  in  turn- 
ing the  patient,  first  on  her  back,  and  next  partially 
on  her  right  hip,  so  that  the  bandage  can  be  un- 
folded and  brought  smoothly  dowm  on  the  back  and 
left  side,  at  the  same  time  that  the  end  of  the  peri- 
naeal  napkin  is  made  smooth  and  strait  upon  the  sa- 
cral portion  of  the  pelvis ; — dry  cloths  being  neatly 
placed  over  those  which  were  soiled  during  the  labor, 
the  patient  may  be  returned  upon  her  back,  gently 
extending  the  limbs,  the  two  ends  of  the  bandage, 
which,  by  this  plan,  will  be  found  to  adapt  themselves 
to  each  other,  can  now  be  overlapped  on  compresses 
of  greater  or  less  thickness,  as  required,  and  neatly 
pinned,  or  better  still,  securely  laced  with  a  strong 
needle  and  large  thread,  as  before  mentioned. 

Should  this  bandage  be  applied  very  tightly  ?  If 
the  uterus  has  well  contracted  into  a  small  globe  in 
the  hypogastric  region,  the  bandage  is  needed  only  to 
give  support  from  without  to  substitute  the  distension 
to  which  it  had  been  subjected  from  within : — but  if 
the  uterus  appear  indisposed  to  contract  firmly,  or  if 
there  be  any  signs  of  hemorrhage,  it  will  be  proper  to 
draw  the  bandage  tightly  over  the  patient's  pelvis  and 
lower  part  of  the  abdomen. 

Is  it  important  whether  the  bandage  is  pinned  or 
laced  from  below,  upward,  or  in  the  reverse  direction  ? 
Opinions  and  practices  differ  in  respect  to  this.  Some 
thinking  it  an  object  to  make  the  intestines  descend 
quickly  towards  the  pelvis  to  the  position  they  occu- 
pied previous  to  the  latter  periods  of  pregnancy  com- 
mence the  closing  of  the  bandage  upon  the  epigastric 
region,  and  thence  descend  as  low  as  they  deem  expe- 
dient. Others  considering  the  faintness  which  the 
patient  often  experiences  after  delivery  depends  par- 
tially, at  least,  upon  the  sudden  return  of  the  bowels 


DELIVERY — DUTIES    OF   ATTENDANTS.  165 

out  of  tlieir  places  of  confinement  hj  the  recent  pres- 
sure of  the  uterus,  begin  the  process  of  closing  the 
bandage  from  below  the  pubes  upwards  to  the  lower 
margins  of  the  mammae,  but  leaving  it  rather  less 
tight  above  than  below.  Whatever  theories  may  be 
indulged  in,  in  this  matter,  the  general  experience  is, 
that  the  patient  appe.ars  the  soonest  to  begin  to  derive 
comfort  when  the  upper  part  of  the  thighs  are  band- 
aged first,  and  it  is  probably  true,  that  in  most  cases 
it  is  best  to  begin  the  tightening  of  the  bandage  from 
below  upwards. 

HOW  TO  PUT  PATIENT  UP  IN  THE  BED. 

How  long  should  the  patient  remain  in  the  flexed 
position  on  this  part  of  the  bed  after  delivery  ?  Un- 
less she  has  been  greatly  prostrated  by  long  or  violent 
labor,  or  by  hemorrhage,  it  is  most  humane,  to  have  her 
placed  comfortably  upon  the  dry  part  of  the  bed  which 
had  been  previously  prepared  for  her  as  a  resting 
place.  Unless,  therefore,  she  be  in  the  condition 
mentioned,  or  there  be  a  deficiency  of  proper  assist- 
ance to  slide  her  without  the  least  efibrt  on  her  part, 
she  should  certainly  be  placed  up  in  the  position  ulti- 
mately intended  for  her  as  soon  as  practicable. 

How  may  this  be  done  with  the  least  possible  fa- 
tigue to  herself  and  embarrassment  to  the  attendants  ? 
Let  her  be  covered  by  a  sheet  or  blanket,  from  her 
shoulders  to  her  feet,  thrown  into  longitudinal  folds  or 
plaits,  so  that  in  width  it  will  just  cover  her  person : 
if  she  be  a  small  woman  and  on  a  low  bed,  it  may  be 
possible  for  a  strong  woman  or  the  physician  himself 
to  convey  her  to  her  appropriate  place,  while  the 
nurse  is  attending  to  the  removal  of  the  soiled  bed  and 
sheet  which  were  under  and  about  her ;  but  if,  as  is 
perhaps  most  commonly  the  case,  the  bed  is  high,  it 
will  be  best  that  the  physician  or  the  husband  should, 
with  one  foot  on  each  side  of  the  patient,  and  a  hand  in 
each  axilla,  be  prepared  to  lift  the  greater  part  of  her 
weight,  and  by  an  adroit  motion   carry  her  half  way 


166  DELIVERY — DUTIES    OF   ATTENDANTS. 

to  the  spot  intended  for  her  to  occupy  during  the 
first  hours  of  repose ;  the  nurse,  meanwhile,  should 
have  laid  off  from  the  hips  and  limbs  of  the  patient, 
the  sheet  or  blanket  which  had  surrounded  her,  (keep- 
ing her  of  course  carefully  covered  by  the  loose  one 
which  had  been  just  placed  upon  her,)  she  should  take 
the  heels  of  the  patient  in  the .  palm  of  one  hand^ 
while  with  the  other,  she  should  seize  upon  the  margin 
of  all  the  clothes  which  are  to  be  removed  from  under 
the  patient.  At  a  signal  understood  between  the  two 
persons  thus  employed  in  removing  the  patient,  the 
nurse  assisting  to  place  her  up,  quickly  draws  out 
from  under  the  patient  all  the  clothes  upon  which 
she  had  laid  across  the  bed,  while  the  other  hand  is 
also  aiding  in  sliding  her  up.  Having  by  this  co-ope- 
rative movement  placed  her  half  way,  or  perhaps 
rather  more,  towards  the  place  for  her  head  and 
her  hips,  and  having  all  the  soiled  clothes  removed,  the 
nurse  can  now  extend  her  left  arm  under  the  cover, 
up  the  spinal  column  of  the  patient,  take  hold  of  the 
lower  edge  of  the  folded  chemise,  and,  at  the  next 
signal  given,  to  complete  the  upward  movement  of  the 
mother,  she  will  find  it  not  difficult  to  bring  down  the 
back  and  the  lower  portion  of  her  under-dress. 

Is  it  not  often  well  to  leave  the  under  garments  of 
the  patient  folded  up  for  some  time  after  putting  her 
up  in  bed  till  after  the  first  discharges  have  time  to 
escape  from  her  body  ?  With  the  consent  of  the  pa- 
tient, it  would  usually  be  well  to  allow  the  chemise  to 
remain  for  a  few  hours  above  all  risk  of  being  soiled, 
should  the  napkins  applied  be  not  quite  suflicient  to 
collect  all  which  might  escape.  By  this  arrangement 
it  will  also  be  more  easy  for  the  nurse  to  have  access 
to  the  hips  of  the  mother  to  ascertain  the  condition  of 
the  napkin,  and  to  change  it  if  necessary  without 
much  if  any  disturbance  to  the  weary  woman. 

What  dangers  may  arise  from  close  compression  of 
the  vulva  by  the  napkin  ?  It  may  arrest  the  discharge 
of  the  blood  from  the  vagina,  plug  it  up  by  a  coagu- 


DELIVERY — DUTIES    OF    ATTENDANTS.  1G7 

lum,  and  thus  obscure  hemorrhage  in  some  cases. 
The  cloth  should  therefore  be  applied  loosely  but 
closely  to  the  vulva. 

What  position  is  most  comfortable  for  the  patient 
when  she  is  carried  up  into  the  place  intended  for  her 
to  lay  in  after  delivery  ?  She  mostly  prefers  to  lay 
on  the  left  side  with  her  limbs  partially  flexed,  and 
her  head  on  a  pillow  of  moderate  height ;  and  it  will 
contribute  to  her  comfort  to  have  a  pillow  placed  along 
her  back  so  as  to  support  her  loins  and  shoulders. 

What  other  attention  should  she  next  receive  ? 
The  nurse  having  adjusted  the  body,  bed  and  head- 
dress comfortably,  she  should  be  supplied  with  some 
cool  drink  or  light  nourishment. 

May  she  rise  up  in  bed  to  take  it  ?  She  should  not 
be  allowed  to  rise  up  for  any  purpose  for  several  days 
after  her  delivery.  Her  drinks  and  fluid  nourish- 
ment should  be  given  her  from  a  spout-cup  or  a  tube, 
or  by  a  spoon. 

ATTENTIONS  TO  BE  GIVEN   TO  THE  CHILD. 

Which  should  be  attended  to  first  after  delivery, 
the  mother  or  child  ?  Circumstances  will  necessarily 
determine,  whether  attention  may  not  be  given  to 
both  simultaneously,  if  there  be  sufficient  assistance 
in  the  room,  or  whether  mother  or  child  shall  have 
the  precedence  of  the  care  of  those  present — gene- 
rally the  child  will  suffer  little  or  no  inconvenience  by 
remaining  wrapped  warmly,  until  after  the  mother 
shall  have  been  fully  attended  to,  while  perhaps,  in 
most  cases,  it  would  be  unsafe  to  withdraw  all  atten- 
tion from  the  mother  for  the  sake  of  washing  and 
dressing  the  child  as  soon  as  it  is  born. 

WASHING  THE  CHILD. 

Should  the  practitioner  pay  attention  to  the  mode 
of  washing  the  child  ?  He  should  carefully  superin- 
tend this  process. 

How  should"  the  nurse  get  rid  of  the  sebaceous  mnt- 


168  DELIVERY — DUTIES    OF   ATTENDANTS. 

ter  which  raostlj  covers  it  ?  By  the  free  application 
of  unctuous  matter,  the  best  of  which  is  animal  oil, 
as  lard,  &c. 

What  kind  of  soap  should  be  used  ?  It  should  be 
mild,  bland,  and  not  strongly  alkaline. 

Should  the  nurse  use  brandy,  &c.,  on  all  occasions? 
It  is  by  no  means  necessary  on  all  occasions.  It 
need  not  be  used  unless  the  child  is  in  a  very  feeble 
or  asthenic  state. 

Cannot  the  child's  skin  be  made  clean,  in  many 
cases,  without  the  use  of  water  at  the  first  washing  ? 
In  many  and  perhaps  in  most  instances,  the  free  ap- 
plication of  lard  upon  every  part  of  the  surface  of 
the  child  will  so  completely  detach  all  the  matter 
which  was  adhering  to  it,  that  it  can  be  wiped  per- 
fectly clean  afterwards,  by  a  fine  sponge,  or  soft  flan- 
nel cloth.  It  is  probable  that  by  the  general  adoption 
of  the  plan  of  making  the  first  ablution  of  the  child 
with  lard  simply,  it  would  suffer  less  than  it  often 
does  by  the  use  of  water  and  soap,  which  evaporates 
so  rapidly  as  to  chill  the  surface  greatly,  unless  the 
nurse  be  very  careful  in  drying  and  wrapping  it  up, 
as  she  performs  the  duty  in  this  way. 

DRESSING  THE  UMBILICAL  CORD. 

How  should  you  dress  the  cord  ?  Take  a  piece  of 
linen  about  six  inches  square,  cut  it  in  a  central  hole, 
through  this  draw  the  umbilical  cord,  then  fold  this 
linen  up  in  such  a  manner  as  to  envelope  the  cord 
completely,  keeping  its  cut  extremity  directed  toward 
the  child's  chin.  A  more  simple  method,  and  one 
which  we  prefer  to  this,  is,  to  take  a  piece  of  linen 
about  four  inches  wide  and  ten  long,  and  cut  into  the 
middle  of  one  of  its  extremities,  a  slit  about  an  inch  long. 
Holding  the  cord  at  right  angles  with  the  body,  this 
slit  is  to  be  drawn  from  above  downward,  to  fit  closely 
to  the  root  of  the  cord.  This  is  then  to  be  turned 
up  toward  the  chin,  one  of  the  lateral  portions  of  the 
linen  is  to  be  turned  over  in  front  of  it,  and  then  the 


DELIVERY — DUTIES    OF    ATTENDANTS.  169 

other  in  the  same  manner.  Next  raise  the  upper  end 
of  the  cord,  and  fold  these  three  layers  of  linen  un- 
der it,  until  there  will  thus  be  seven  thicknesses  of  the 
linen  interposed  between  the  cord  and  the  teguments 
of  the  abdomen.  The  balance  of  the  linen  folds,  if 
any,  may  be  brought  down  in  front  of  the  cord.  It 
will  in  this  manner  be  sufficiently  isolated  from  the 
body  of  the  child,  and  the  dressing  can  be  easily 
renewed  if  necessary.  Over  this,  as  in  the  other  case, 
a  roller  of  flannel,  just  wide  enough  to  reach  from  the 
axillae  to  the  hips,  is  to  be  fastened. 

What  is  the  object  in  thus  enveloping  the  cord  ? 
To  prevent  the  contact  of  it,  as  a  putrefying  mass, 
with  the  surface  of  the  abdomen,  and  thus  causing 
great  irritation  of  the  skin. 

USES  OF  THE  BANDAGE  UPON  THE  BODY  OF  THE  CHILD. 

What  is  the  principal  object  of  the  belly-band  or 
roller  ?  Merely  to  support  the  cord  in  its  proper  situ- 
ation, and  retain  the  dressings  upon  it. 

How  long  should  this  bandage,  binder,  or  roller  be  ? 
Merely  sufficient  to  encircle  the  body  once  and  over- 
lap to  be  secured  by  pinning  or  stitching. 

Should  you  allow  the  nurse  to  pin  the  roller  tight  ? 
It  should  never  be  pinned  so  tight  as  to  interfere 
with  muscular  motion,  whether  respiratory  or   other- 


DRESSING  THE  CHILD. 

How,  in  other  respects,  may  the  child  be  dressed  ? 
According  to  the  desire  of  the  mother  or  friends, 
provided  the  clothing  be  such  as  to  keep  the  child 
sufficiently  warm,  and  allow  it  sufficient  freedom  of 
motion. 

Are  any  cautions  necessary  for  the  nurse  to  observe 

in   reference  to  the  diaper  or  napkin  for  the  child's 

hips  ?     The  nurse  should  be   careful  that  the  diaper 

should  not  be  so  thick  and  so  stiff  as  to  keep  the  limbs 

15 


170  DELIVERY — DUTIES    OF    ATTENDANTS. 

too  widely  separated,  or  too  much  excluded,  or  that 
the  mass  of  it  be  too  heavy  for  the  newly  born 
child  ;  the  napkin  should  therefore  be  made  of  soft 
old  materials,  and  as  nearly  as  can  be  calculated,  be 
of  size  and  thickness  merely  sufficient  to  receive  the 
small  quantities  of  meconium  and  urine  the  child  may 
discharge  in  the  course  of  only  a  few  hours  before  it 
may  be  convenient  to  change  it. 

PRESENTATION  OF  THE  CHILD  TO  THE  MOTHER. 

If  the  mother  have  been  put  up  carefully  and  com- 
fortably in  bed,  as  soon  after  delivery  as  could  be 
done  after  the  proper  adjustment  of  her  napkin  and 
bandage,  and  have  had  time  to  repose  while  you  were 
superintending  the  cleaning  and  dressing  the  child, 
what  should  be  your  next  duty  in  the  lying-in  cham- 
ber ?  To  receive  the  child  from  the  lap  of  the  nurse, 
to  hold  it,  until  she  shall  have  cautiously  opened  the 
bosom  of  the  mother  and  prepared  the  nipple  of  the 
lower  breast,  for  its  application  to  it, — then  allowing 
the  mother  a  few  moments  to  embrace  her  offspring, 
put  it  so  closely  to  her  side  that  its  head  may  repose 
upon  her  lower  arm,  and  that  its  mouth  may  embrace 
and  suck  the  nipple. 

Why  not  allow  the  nurse  to  give  it  some  butter  and 
sugar,  some  molasses  and  oil,  molasses  and  water,  or 
sugar  and  water,  or  a  little  of  its  mother's  food,  as  a 
table  spoonful  or  two  of  gruel,  panada,  or  cracker- 
victuals  ?  Because  none  of  these  things  are  ever  neces- 
sary for  a  child  just  born,  and  in  nearly  every  in- 
stance in  which  improprieties  should  be  indulged  in, 
the  child  would  be  subjected  to  great  suffering,  from 
incapacity  to  assimilate  such  food. 

How  long  should  the  child  be  permitted  to  remain 
drawing  the  nipple  ?  If  the  mother  be  strong,  if  she 
have  a  firm  well  developed  nipple,  no  inconvenience 
will  probably  result  to  her  from  allowing  the  child  to 
draw  at  it  for  several  minutes,  whether  there  be  any 
milk  in  the  breast  or   not ;  but  if  the  nipple  be  ten- 


DELIVERY — DUTIES    OF   ATTENDANTS.  171 

der,  the  mother  nervous,  irritable,  and  the  efforts  of 
the  child  excite  violent  uterine  contractions,  it  should 
be  taken  from  her  and  placed  in  a  soft  warm  bed  by 
itself,  that  both  it  and  the  mother  may  be  allowed  to 
have  repose  in  sleep. 

If  the  child  cry  much,  and  the  mother  has  no  milk 
in  her  breasts,  how  should  it  be  treated  ?  Under  such 
circumstances  it  may  be  proper  to  allow  the  nurse  to 
give  it  a  few  tea-spoonsful  of  simple  water,  or  water 
with  a  little  sugar  in  it,  or  perhaps  a  little  milk  to 
which  an  equal  quantity  of  boiling  water  has  been 
added,  and  allowed  to  cool. 

ADMISSION  OF  COMPANY  INTO  THE    LYING-IN  ROOM. 

When  would  it  be  proper  to  admit  company,  as 
members  of  the  patient's  family,  relatives  or  intimate 
friends  into  her  room  ?  Certainly  not  until  she  shall 
have  recovered  from  the  fatigue  of  her  recent  effort, 
and  the  iihmediate  dangers  of  her  puerperal  condition 
— the  first  certainly  requires  several  hours,  and  the 
last  mostly  several  days. 

DUTIES  OF  PHYSICIAN  AND  NURSE  TOWARDS  THE 
PATIENT'S  HUSBAND. 

What  regard  should  be  paid  to  the  husband  during 
the  labor  and  at  the  time  of  delivery  of  his  wife,  and 
the  birth  of  their  child  ?  If  he  be  a  prudent  man, 
of  good  moral  force,  competent  to  comfort,  encourage 
and  aid  in  sustaining  his  wife  through  the  conflict  of 
parturition,  and  to  calm  and  compose  her  in  the  ex- 
citement or  ecstacy  to  which  she  is  often  subject  upon 
delivery,  it  will  in  most  cases  be  the  duty  of  physi- 
cian and  nurse  to  make  his  presence  acceptable  during 
the  whole  time  it  is  expedient  for  the  physician  him- 
self to  remain  with  the  patient,  inasmuch  as  the  con- 
jugal relation,  strictly  interpreted,  would  enjoin  the 
parties  mutually  to  assist  each  other,  at  this  as  well 
as  any  other  period  of  matrimonial  life.  Since,  how- 
ever, the  accidents  and  dangers  to  which  the  woman 


172  DELIVERY— DUTIES    OF   ATTENDANTS. 

is  subject  during  this  and  its  immediately  succeeding 
eventful  epoch,  are  often  of  the  most  important  charac- 
ter, it  is  requisite  to  place  the  management  of  the 
case  in  charge  of  some  one,  who,  by  proper  training, 
ought  to  possess  capability  for  acting  in  emergencies 
which  may  occur  in  this  condition,  manifold  more 
wisely  than  the  ordinary  citizen,  wdiatever  his  general 
intelligence.  The  husband,  whether  present  or  ab- 
sent, must  regard  the  physician  and  nurse  as  substi- 
tutes, or  attorneys  to  whom  is  deputed  the  entire  con- 
trol of  the  affairs  of  the  chamber  and  nursery  for  the 
time  being — and  his  conduct  should  be  regulated  by  a 
high  sentiment  of  propriety,  or  by  the  suggestions  of 
the  physician.  Doubtless  every  husband  who  pos- 
sesses the  proper  attributes  of  a  man,  will  desire  to  be 
in  or  near  his  wife's  apartments  during  the  diversified 
conflict  of  body  and  soul  to  which  she  will  be  subject, 
during  the  hours  of  labor,  and  at  the  moment  of  child- 
birth ;  but  whether  he  shall  be  actually  present  during 
the  whole  of  this  period,  may  be  a  question  of  expe- 
diency to  be  settled  mutually  by  her,  himself  and  the 
physician.  The  latter  to  whom  is,  or  ought  to  be  de- 
legated the  responsibilities  of  the  case,  under  such 
circumstances,  must  have  a  scrupulous  regard  to  the 
introduction  of  a  properly  co-operative  influence,  or 
the  exclusion  or  removal  of  any  which,  in  his  opinion, 
may  prove  detrimental  to  the  safe  conduct  of  the 
affair. 

Is  it  proper  that  the  husband  should  be  introduced 
into  the  room,  by  the  time  the  mother  and  the  child 
are  placed  together  in  the  bed  ?  It  is  due  to  the  hus- 
band, first  that  he*  should  have  the  satisfaction  of 
realizing  the  happy  termination  of  his  anxieties,  and 
in  the  next  place  it  is  due  to  the  nurse  and  to  the  pa- 
tient that  an  opportunity  should  be  aff'orded  to  her  of 
having  the  instructions  of  the  physician  respecting  the 
hygienic  treatment  of  the  mother  and  child  made 
in  the  presence  of  the  husband  and  father  that  he  may 
fully  understand,  and  co-operate  in  executing  them. 


DELIVERY — DUTIES    OF   ATTENDANTS.  173 


TREATMENT  OF  THE    PATIENT  IMMEDIATELY  AFTER 
DELIVERY. 

Should  you  keep  the  patient  in  the  horizontal  posi- 
tion for  several  days  ?  This  should  be  done  to  avoid 
the  risk  of  hemorrhage  or  of  prolapsus,  &c. 

What  kind  of  diet  may  she  be  allowed  ?  Very 
light — as  gruel,  panada,  barley  water,  toast  Avater, 
crackers,  &c. 

What  kind  of  drinks  should  she  have,  and  at  what 
temperature  should  they  be  administered  ?  Cool, 
simple  drinks.  If  feverish,  water  with  sweet  spirits 
of  nitre. 

AFTER-PAINS. 

Is  the  woman  subject  to  pains  subsequent  to  de- 
livery ?  Most  women  recently  delivered,  except 
some  of  those  with  their  first  children,  have  at- 
tacks of  spasmodic  uterine  pain,  a  short  time  after 
delivery. 

What  is  their  character  ?  They  are  spasmodic,  al- 
ternate, and  neuralgic. 

What  is  the  usual  cause  ?  Some  think  they  are 
owing  to  the  presence  of  coagula  in  the  uterus. 

Do  they  ever  depend  upon  the  particular  condition 
of  other  organs  ?  They  sometimes  no  doubt  depend 
upon  certain  conditions  of  the  stomach,  bowels,  and 
even  bladder. 

Should  you  always  inquire  into  the  cause  before 
prescribing  for  them  ?  This  should  be  done  with 
much  care,  as  the  indication  of  treatment  differs 
greatly. 

How  should  you  treat  them,  when  they  depend 
upon  the  condition  of  the  nervous  system?  They 
should  be  allayed  by  anodynes,  the  best  of  which  are 
camphor,  morphia,  &c. 

Should  you  ever  direct  warm  injections  for  the  re- 
lief of  after  pain  ?  Whenever  they  appear  to  depend 
upon  the  existence  of  any  irritation  in  the  bowels,  as 
tiatu'encc,  faeces,  &c. 

15* 


174  DELIVERY— DUTIES    OF   ATTENDANTS. 

Are  there  any  cases  in  which  vascular  depletion  be- 
comes useful  ?  Whenever  there  is  a  plethoric  or  fev- 
erish condition  of  the  system. 

Is  it  ever  necessary  to  evacuate  the  bladder  by  the 
catheter  ?  It  is  necessary  to  ascertain  the  condition 
of  the  bladder,  and  if  full,  relieve  it  by  the  catheter. 

Are  there  any  cases  of  misplaced  after  pains  ? 
When  pains  attack  the  region  of  the  coccyx,  the 
knee,  other  joints,  they  may  be  so  considered. 

How  would  you  treat  this  variety  ?  By  the  free 
use  of  anodynes. 

Are  after  pains  ever  dependant  upon  the  want  of 
tonic  contraction  of  the  uterus  ?  They  probably 
mostly  depend  upon  inefficient  contraction  of  the  ute- 
rus ;  and  are,  therefore,  to  be  obviated  by  procur- 
ing the  complete  contraction  of  the  organ.  They  are 
often  prevented,  or  if  they  occur,  may  be  often  re- 
lieved by  free,  long  continued  friction  over  the  uterus 
soon  after  delivery.  It  is  also  strongly  recommended 
by  some  teachers  to  examine  the  vagina  and  os  uteri, 
and  if  there  be  coagula  in  them  carefully  to  turn 
them  out. 

USUxVL  CHANGES   IN  THE    CONDITION    OF  THE   PUERPE- 
RAL WOMAN. 

What  duties  does  the  accoucheur  owe  to  the  puer- 
peral woman  during  several  consecutive  days  after  her 
parturient  effort  ?  He  should  inform  himself  through 
the  medium  of  the  nurse  respecting  the  condition  of 
the  uterus  as  evinced  by  the  frequency  or  severity  of 
the  after  pains ;  he  should  ascertain  the  condition  of 
the  bladder,  and  if  the  patient  has  not  been  relieved, 
within  ten  or  fifteen  hours  after  the  delivery,  he 
should,  if  necessary,  draw  off  the  urine  by  a  catheter. 

URINE. 

How  long  can  a  patient  be  left  without  passing  her 
water  ?  Some  patients  after  delivery  have  retained 
the  urine  for  thirty-six  or  more   hours   without  much 


DELIVERY — DUTIES    OF   ATTENDANTS.  175 

pain  or  inconvenience,  while  some  others  feel  occasion 
to  p.ass  large  amounts  of  fluid  from  the  bladder  shortly 
after  delivery.  As  the  rule  of  conduct  of  the  physi- 
cian he  should  satisfy  himself  by  enquiry  whether  or 
not  she  suffers  any  inconvenience  in  this  respect ;  and 
if  she  do,  he  should,  if  he  think  it  safe,  encourage 
her  to  make  the  effort  in  the  horizontal  or  partially 
inclined  position,  while  he  is  in  another  room.  If  she 
fail  to  urinate,  he  should  afford  her  aid  by  a  catheter. 
If,  however,  she  feels  neither  inconvenience  from  re- 
tention, nor  desire  for  relief,  it  may  be  safe  to  delay 
the  use  of  instrumental  means  for  a  few  hours  longer. 

LOCHIA. 

What  is  the  usual  amount  of  lochia  during  the  first 
twenty-four  hours  after  delivery  ?  While  it  is  very 
variable  in  different  cases,  and  even  in  the  same  pa- 
tient at  different  times  after  delivery,  it  may  perhaps, 
be  taken  for  an  average,  that  she  will  have  an  occasion 
to  employ  the  nurse  to  remove  six  napkins  well  filled 
during  the  first  six  hours ;  four  during  the  second ; 
two  in  the  third,  and  one  in  the  last  six  of  the 
twenty-four  hours  after  delivery. 

What  diminution  will  probably  take  place  during 
the  next  twenty-four  hours  ?  She  will  probably  re- 
quire upon  an  average  one   napkin  every  six   hours. 

MILK. 

What  is  the  usual  condition  of  the  lactiferous  ap- 
paratus of  the  woman  recently  delivered  ?  It  is  va- 
riable— some  women  having  the  gland  in  an  active 
state,  and  secreting  milk  freely,  while  in  many  this 
function  remains  dormant  for  two,  three,  four,  or  five 
days  after  the  birth  of  the  child. 

What  changes  of  condition  does  the  patient  usually 
experience  upon_the  effort  of  the  glands  to  secrete 
milk  ?  Diminution,  or  temporary  suspension  of  the 
lochia,  more  or  less  chilliness,  with  flushes  of  heat — 
sometimes  a  real  shivering  fit,  followed  by  violent  fc- 


176  DELIVERY — DUTIES    OF   ATTENDANTS. 

ver,  with  severe  headache,  pain  in  the  back,  &c.,  fol- 
lowed by  perspiration  and  fulness  of  the  breasts,  or 
the  free  flow  of  milk  from  the  nipples. 

TORPOR  OF  THE  BOWELS. 

What  IS  the  usual  condition  of  the  bowels  of  the 
puerperal  woman  ?  They  are  usually  torpid  for  sev- 
eral days,  especially  till  after  the  milk  is  secreted. 
Upon  the  establishment  of  this  function  they  some- 
times act  spontaneously,  but  in  many  patients  they 
require  to  be  aided  by  some  means. 

GETTING  UP. 

When  may  the  patient  get  up  from  her  bed  after 
parturition  ?  In  relation  to  the  precise  time  when  a 
patient  may  venture  to  resume  the  upright  position 
no  settled  rule  can  well  be  established,  and  the  physi- 
cian having  charge  of  the  case  must  determine  after 
due  consideration,  when  he  can  instruct  or  allow  the 
nurse  to  take  the  patient  from  her  recumbent  to  an 
upright  position.  However  urgent  the  patient,  nurse 
or  friends,  may  be  to  withdraw  all  restraint  to  her 
getting  about  soon,  and  however  numerous  the  cases 
they  may  cite  in  which  such  indulgences  have  been 
tolerated  with  impunity,  it  is  certain  that  too  many 
dangerous  and  even  fatal  consequences  have  ensued 
upon  premature  rising  from  or  even  in  the  bed  to  ex- 
cuse the  physician  in  countenancing  much  latitude  in 
this  respect.  Women  who  have  risen  upon  their  el- 
bows to  embrace  their  husbands  upon  their  introduc- 
tion into  the  chamber  after  delivery — women,  who 
have  been  prompted  by  their  attendants  to  rise  while 
the  bed  and  personal  clothing  were  changed — women, 
who  with  a  determination  to  sit  upon  a  chamber-vessel 
to  urinate  shortly  after  parturition,  and  women  also 
who  have  at  the  recommendation  of  nurses  sat  up  in 
bed  for  the  purpose  of  evacuating  something  which 
caused  a  nisus  in  the  perinoeal  region,  have  forfeited 
their  lives  or  their  health,  for  this  departure  from  ap- 


DELIVERY — DUTIES    OF    ATTENDANTS.  177 

propriate  conduct  after  their  organs  have  undergone 
the  rapid  changes  incident  to  parturition.  It  ought, 
therefore,  to  be  a  part  of  the  physician's  duty  to  keep 
a  vigilant  eye  to  the  condition  of  his  patient,  to  deter- 
mine as  to  the  time  when,  as  well  as  the  manner  in 
which,  she  is  to  be  gotten  out  of,  or  even  lifted  up  in 
bed.  Whenever  practicable  it  should  be  the  rule  of 
duty  to  keep  her  in  bed  till  her  milk  is  fairly  secreted, 
and  the  free  discharge  of  the  lochia  has  somewhat 
abated,  and  the  soreness  and  stiffness  have  entirely 
subsided  and  she  is  quite  able  to  turn  herself  from  one 
side  of  the  bed  to  the  other.  After  this,  which  will 
usually  require  from  four  to  five  days,  she  might  be 
allowed  to  sit  upright  in  the  bed,  or  possibly  be  lifted 
from  one  bed  to  another  till  both  the  bed  and  her  body 
clothing  have  been  thoroughly  changed.  From  this 
period,  if  no  accident  have  happened,  it  will  be  proper 
to  allow,  encourage,  or  direct  her  to  sit  up  in  bed,  not 
only  to  nurse  her  child,  but  to  make  her  ablutions  and 
take  her  food  not  only  for  longer  periods,  but  also  more 
frequently.  By  the  eighth  or  ninth  day,  she  mostly  may 
with  safety  be  allowed  to  be  seated  in  her  arm  chair, 
and  to  recline  backwards,  or  to  sit  quite  upright,  for 
an  hour  or  two  at  a  time.  After  the  lapse  of  one  or 
two  days  spent  in  this  training  and  testing  her  condi- 
tion, she  may  be  assisted  by  some  one  to  walk  a  little, 
and  shortly  after  having  acquired  sufficient  strength 
by  these  means,  she  may  begin  gradually  to  resume 
her  household  duties. 

USUAL  CONDITION  OF  THE  CHILD  DURING  THE  FIRST 
FEW  DAYS  AFTER  ITS  BIRTH. 

What  is  the  usual  condition  of  the  child  during  the 
first  few  days  of  its  birth  ?  In  the  early  hours  of  its 
extra-uterine  life  it  is  most  inclined  to  remain  flexed 
upon  one  side  nursing  or  sleeping,  expressing  no  un- 
easiness, except  when  its  clothes  bind  it  too  tightly  or 
its  diaper  has  become  wetted  or  soiled.  In  a  sufficient 
number  of  cases,  the  child  will  be  found  to  cry  more  or 


178  DELIVERY — DUTIES    OF   ATTENDANTS. 

less,  even  when  there  are  no  apparent  causes  of  dis- 
turbance, and  both  mother  and  nurse  become  so  an- 
noyed or  distressed  by  it  as  to  be  tempted  to  resort  to 
some  artificial  means  of  quieting  it  by  giving  it  warm 
teas,  as  those  of  catnip,  aniseed,  &c.,  or  under  an  impres- 
sion that  it  is  hungry,  will  feed  it  with  gruel,  bread  and 
water,  or  boiled  crackers,  &c.,  neither  of  which  can  be 
suitable  food  for  it. 

STATE  OF  BOWELS. 
What  changes  do  its  alvine  discharges  undergo  ?  At 
first  they  are  dark,  have  the  consistence  of  tar,  or 
thick  molasses  ;  in  the  course  of  two  or  three  days  they 
often  become  greener,  thinner,  and  interspersed  with 
yellow  specks,  and  shortly  after  it  can  get  a  full  supply 
of  milk,  they  become  almost  uniformly  yellow.  The 
child  while  these  changes  are  taking  place  is  usually  less 
disposed  to  sleep,  often  expresses  much  uneasiness,  and 
even  sometimes  sufiers  greatly  from  colic,  or  tenesmus, 
and  diarrhoea. 

CONDITION  OF  SKIN. 

What  changes  does  its  skin  undergo  ?  In  a  day  or 
two  after  birth  the  skin  often  presents  a  straw  or  or- 
ange color,  even  the  adnata  become  tinged,  but  com- 
monly, when  the  intestinal  secretions  assume  the  pro- 
per yellow  and  consistent  appearance,  this  yellowness 
of  the  skin  subsides.  Very  frequently  in  the  course 
of  a  few  days  after  birth  the  skin  becomes  covered  in 
places  with  a  miliary  eruption,  but  still  more  com- 
monly the  exanthem  is  in  red  or  yellow  patches,  a  va- 
riety of  cutaneous  affection  technically  called  strophu- 
lus intertinctus,  or  in  nursery  language  red  gum  or 
red  gown. 

DECADENCE  OF  THE  CORD. 

When  does  the  umbilical  cord  usually  separate  from 
the  umbihcus  or  navel?  The  period  of  the  complete 
decadence  of  the  cord  is  variable,  ranging   from  two 


LABOR  — PELVIC    PRESENTATIONS. 


179 


days  to  more  than  two  weeks.  Perhaps  the  average 
time  required  for  the  sloughing  away  of  this  extran- 
eous matter  is  about  five  days. 

What  is  the  usual  condition  of  the  umbilicus  itself 
at  the  time  of  the  falling,  off  of  the  cord  ?  In  most 
cases  which  have  been  properly  nursed,  the  umbilical 
surface  exhibits  a  moist  slightly  red  appearance  which 
dries  up,  and  is  covered  by  a  skin  in  a  few  more  days. 

SECOND  CLASS  OF  PRESENTATIONS— PRESENTATIONS  OP 
THE  PELVIC  EXTREMITY  OF  THE  FETAL  ELLIPSE. 

What  may  be  regarded  as  the  second  class  of  pre- 
sentations of  the  fetus  in  utero  ?  That  in  which  the 
pelvic  pole  of  the  fetal  ellipse  offers  to  the  os  uteri 
while  the  cephalic  pole  is  at  or  near  the  fundus  of  the 
organ,  as  shewn  in  fig.  69. 


Fig.  69. 


Why  are  they  unfavorable  for  the  mother  ?  Because 
of  the  usual  delay  in  the  first  and  second  stages  of 
the  labor,  and  the  consequently  greater  amount  of 
physical  exertion  which  is  necessary  for  her  to  com- 
plete it. 

Are  pelvic  presentations  to  be  regarded  as  danger- 


180       LABOH — PELVIC  PRESENTATIONS. 

ous  for  tlie  child  ?  Thcj  are  to  be  so  regarded,  be- 
cause of  the  liability  of  the  head  to  be  arrested  in  the 
pelvis  of  the  mother,  after  the  body  is  extruded. 

Why  are  they  more  dangerous  for  the  child  ?  Be- 
cause during  the  second  stage,  the  child  is  far  more 
liable  to  be  fatally  compressed,  both  as  regards  the 
cord,  and  the  delay  of  respiration  while  the  head  is 
within,  and  the  body  without  the  uterus. 

DIAGNOSIS  OF  PELVIC  PRESENTATIONS. 

How  are  you  to  diagnosticate  breech  presentations? 
The  OS  uteri  and  bag  of  waters  are  not  quite  so  large 
as  in  the  cephalic  presentations ;  the  finger  can  usually 
detect  a  sulcus  between  the  limbs  ;  sometimes,  also, 
the  genital  organs  can  be  felt,  but  a  still  more  con- 
clusive evidence  presents,  when  in  passing  up  the  fin- 
ger, you  can  feel  the  crista  of  an  ilium  and  the  fold  in 
the  groin. 

Does  the  presence  or  the  absence  of  the  meconium 
afford  any  value  in  the  diagnosis  ?  Usually  it  does 
not,  because  it  is  not  always  present  in  pelvic  presen- 
tations ;  whereas  it  is  sometimes  found  deposited  with- 
in the  inferior  portion  of  the  ovum  in  some  cases  of 
cephalic  presentation. 

What  is  the  first  change  which  the  uterus  effects 
upon  the  form  of  the  child  in  cases  of  breech  presen- 
tations ?  Still  greater  flexion  into  the  form  of  an  el- 
lipse. 

DIFFERENT  POSITIONS  OF  PELVIC  PRESENTATIONS. 

What  are  the  different  varieties  or  positions  of  the 
pelvic  presentations  ?  For  all  practical  purposes  four 
are  sufficient,  but  some  teachers  m"ake  six,  taking  the 
sacrum  for  the  occiput,  and  the  posterior  part  of  the 
thighs  for  the  anterior  fontanelle  into  comparison. 

What  then  is  the  first  position  of  the  breech  presen- 
tations ?  The  sacrum  to  the  left  acetabulum,  and  the 
posterior  part  of  the  thighs  to  the  right  sacro-iliac 
symphysis. 


LABOR — PELVIC   PRESENTATIONS. 


181 


What  the  second  ?  The  sacrum  to  the  right  acetab- 
ulum, and  the  posterior  part  of  the  thighs  to  the  left 
sacro-iliac  symphysis. 

What  the  third  ?  The  sacrum  to  the  symphysis, 
and  the  posterior  part  of  the  thighs  to  the  sacrum  of 
the  mother. 

What  the  fourth  ?  The  sacrum  to  the  right  sacro- 
iliac symphysis,  and  the  posterior  part  of  the  thighs 
to  the  left  acetabulum. 

What  the  fifth  ?  The  sacrum  to  the  left  sacro-iliac 
symphysis,  and  the  posterior  part  of  the  thighs  to  the 
right  acetabulum. 

What  the  sixth  ?  The  sacrum  to  the  sacrum,  and  the 
posterior  part  of  the  thighs  to  the  pubes  of  the  mother. 

MECHANISM  OF  THE  LABOR  IN  PELVIC  PRESENTATIONS. 

What  is  the  mechanism  of  labor  in  the  first  position 
of  breech  presentation  ?  The  uterine  contractions 
compress  the  ovum,  complete  the  fetal  ellipse,  force 
down  the  bag  of  water,  and  after  rupturing  them,  they, 
with  the  aid  of  the  accessory  powers,  cause  the  child 
to  descend  through  the  pelvis  in  the  direction  of  Carus' 
curve. 

How  does  rotation  take  place 
in  this  case  ?  The  left  hip  is  car- 
ried along  the  right  anterior  in- 
clined plane,  and  the  right  along 
the  left  posterior  to  the  median 
line  of  the  sacrum  and  coccyx. 

In  what  direction  does  flexion 
take  place  after  the  hips  are  de- 
livered ?  Laterally,  to  accommo- 
date the  body  to  the  axis  of  the 
pelvis.     Fig.  70. 

Does  restitution  of  the  hips  take 
place  ?  In  many  cases  this  does 
occur  to  some  extent. 

Which  hip  comes  under  the  symphysis  pubes  in  the 
first  position  ?     The  left  hip. 
16 


182      LABOR — DUTIES  OF  PHYSICIAN  AND  NURSE. 


WHAT  TO  DO  WITH  THE  CORD. 

"When  the  body  is  delivered  as  far  as  the  umbilicus, 
what  attention  should  you  give  to  the  cord  ?  Draw 
out  a  fold  of  it  to  prevent  it  from  being  put  too  forci- 
bly upon  a  stretch. 

Fig.  71. 


Suppose  you  find  it  compressed,  how  should  you 
manage  it?  Endeavor  to  raise  up  the  part  which  com- 
presses it,  then  carry  the  cord  to  a  part  of  the  pelvis 
in  which  there  will  be  more  space. 

HOW  TO  MANAGE  THE  BODY  WHEN  EXTRUDED. 

In  what  direction  should  the  body  of  the  child  be 
carried,  to  favor  the  ready  engagement  of  the  head  in 
the  inferior  strait  ?  In  all  the  anterior  varieties  of 
pelvic  presentation,  the  body  should  be  properly 
wrapped  in  a  napkin,  and  carried  towards  the  front 
of  the  abdomen  of  the  mother.     In  the  posterior  va- 


LABOR — DUTIES  OF  PHYSICIAN  AND  NURSE.      183 

rietles,  the  body  is  in  the  same  manner  to  be  carried 
towards  the  sacrum  of  the  mother. 

Do  the  shoulders  rotate  in  the  uterus  at  the  same 
time  that  the  hips  rotate  in  the  pelvis  ?  They  are  be- 
lieved to  remain  fixed  in  the  uterus  until  forced  down 
into  the  pelvis,  after  which  they  obey  the  law  which 
compels  them  to  rotate  on  the  inclined  planes. 

How^  are  the  shoulders  delivered  ?  One  of  them 
passes  on  the  anterior  inclined  plane,  to  appear  under 
the  arch  of  the  pubes,  wdiile  the  other  passes  along  the 
posterior  inclined  plane,  to  appear  in  front  of  the 
coccyx. 

Which  arm  or  shoulder  is  usually  delivered  first  ? 
That  which  passes  over  the  sacrum ;  though  this  rule 
is  not  invariable. 

What  effect  has  the  rotation  of  the  shoulders  upon 
the  neck  of  the  child  ?  It  twists  the  neck  of  the  child 
one-eighth  of  a  circle. 

•  Does  restitution  of  the  shoulders  take  place  after 
they  are  delivered  ?  It  does,  unless  some  resistance 
be  applied  to  the  body. 

Is  it  important  that  the  head  should  present  in  a 
particular  direction,  for  its  safe  delivery  ?  It  is  highly 
important  that  the  head  present  its  mento-occipital 
diameter,  to  the  axis  of  the  pelvis. 

What  hazard  may  result  if  the  practitioner  draw 
forcibly  on  the  body  of  the  child,  as  soon  as  it  is  de- 
livered ?  The  direction  of  the  head  may  be  so  altered 
that  the  mento-occipital  diameter,  instead  of  corre- 
sponding with  the  axis  of  the  pelvis,  becomes  thrown 
across,  to  correspond  with  one  of  its  diameters,  and 
thus  its  delivery  would  be  impracticable. 

In  what  direction  would  the  unaided  efforts  of  the 
uterus  and  abdominal  muscles,  force  down  the  head 
after  the  body  is  expelled  ?  Generally  with  its  mento- 
frontal,  or  mento-occipital  diameter  to  the  axis  of  the 
pelvis. 

Is  there  any  difference  in  the  mechanism  of  the  se- 
cond position  of  the  breech  ?     There  is  uo  essential 


184     LABOR — DUTIES  OF  PHYSICIAN  AND  NURSE. 

diflference  except  that  the  rotation  takes  place  in  an 
order  reversed  from  that  in  the  first  position ;  that  is, 
the  right  hip  and  shoulder  rotate  on  the  left  anterior, 
and  the  left  hip  and  shoulder  on  the  right  posterior 
inclined  plane,  and  the  occiput  on  the  right  anterior 
inclined  plane. 

What  is  the  usual  mechanism  of  the  labor  in  the 
third  position  of  the  breech  ?  Although  the  breech 
may  engage  with  the  sacrum  to  the  pubis  at  the  supe- 
rior strait,  the  hips  and  shoulders  are  mostly  twisted 
upon  the  inclined  planes,  and  thus  come  down  ob- 
liquely, and  finally  present  one  to  the  coccyx,  and  the 
other  to  the  pubes  at  the  inferior  strait. 

Is  the  head  in  any  greater  danger  of  being  arrested 
at  the  superior  strait  in  the  third,  than  in  either  the 
first  or  second  positions  ?  The  mento-occipital  diame- 
ter may  become  wedged  in  the  antero-posterior  diame- 
ter of  the  superior  strait,  and  thus  require  manual  or 
instrumental  assistance  to  disengage  it. 

What  is  the  mechanism  of  the  fourth  position  of  the 
breech  ?  Here  the  sacrum  is  to  the  right  sacro-iliac 
symphysis,  the  right  hip  toward  the  right  acetabu- 
lum, and  the  left  one  toward  the  left  sacro-iliac  sym- 
physis ;  as  the  child  descends,  the  left  hip  is  carried 
down  the  left  posterior  inclined  plane,  and  the  right 
hip  down  the  right  anterior  inclined  plane  to  the  arch 
of  the  pubes  ;  the  shoulders  follow  the  same  route,  the 
occiput  is  driven  down  along  the  right  posterior  in- 
clined plane  to  the  middle  line  of  the  sacrum  and 
coccyx,  to  escape  at  the  posterior  commissure  of  the 
vulva. 

What  is  the  principal  difficulty  in  this  case,  and  that 
of  the  fifth  and  sixth  positions  ?  The  liability  of  the 
head  to  become  arrested  at  the  superior  strait  in  con- 
sequence of  the  chin  being  carried  up  by  the  forced 
curvature  of  the  thorax. 

SUBDIVISIONS  OF  PELVIC  PRESENTATIONS. 
How  are  pelvic  presentations  divided  ?     Into  regu- 


LABOR — DUTIES  OF  PHYSICIAN  AND  NURSE.     185 

lar  and  irregnlar  presentations — or  into  breech,  feet, 
and  knee  presentations. 

Which  of  these  are  regarded  as  irregular  and  unfa- 
vorable ?     Those  of  the  feet  and  the  knees. 

Is  there  any  essential  diiference  in  the  cases  of 
presentation  of  the  feet  and  breech  ?  There  is  nothing 
essential  in  the  mechanism  of  the  labor,  except  that  as 
the  first  stage  is  shorter,  the  second  is  usually  more 
protracted. 

Is  the  child  subjected  to  any  greater  risk  of  its  life 
in  this  than  in  breech  presentationa  ?  It  is  so,  in  con- 
sequence of  the  degree  of  compression  of  the  body,  tho- 
rax, and  neck,  which  are  compressed  by  the  soft  parts 
of  the  mother. 

Why  are  the  shoulders  likely  to  be  delivered  with 
greater  difficulty  in  this  than  in  breech  cases  ?  Because 
as  the  feet  or  knees  make  their  exit  through  the  os 
uteri  before  it  is  much  dilated,  and  then  meet  with 
little  resistance  to  their  descent  in  the  pelvis,  the  os 
uteri  is  liable  to  embrace  the  arms  and  shoulders,  and 
thus  prevent  their  ready  descent. 

How  are  knee  presentations  calculated  ? 

The  anterior  part  of  the  legs  compare  with  the  oc- 
ciput or  the  nape  of  the  neck,  and  the  anterior  part 
of  the  thighs  with  the  anterior  fontanelle  in  cephalic 
presentations. 

What  is  the  best  direction  to  be  given  to  the  patient 
during  the  first  stage  of  labor  in  reference  to  her 
bearing  down  ?  As  it  is  desirable  to  prolong  the  first 
stage  of  labor  in  all  the  pelvic  presentations,  espe- 
cially in  these  cases,  she  should  be  urged  not  to  bear 
or  force  down. 

Suppose  you  find  her  strongly  disposed  to  do  so, 
what  precautions  should  you  take  not  to  allow  the 
membranes  to  be  ruptured  too  early  ?  Oblige  her  to 
lie  down ;  if  she  have  intestinal  or  vesical  irritation, 
calm  them  by  anodyne  enemata ;  if  she  cough,  tran- 
quillize it  by  some  suitable  anodyne. 

When  you  diagnosticate  any  of  the  pelvic  prescn- 
16* 


186     LABOK — DUTIES  OF  PHYSICIAN  AND  NURSE. 

tations,  should  you  make  any  effort  to  deliver  the 
child  while  it  is  yet  in  the  uterus  ?  Never,  unless 
some  accident  should  complicate  the  labor,  as  convul- 
sions, hemorrhage,  &c.,  and  then,  not  unless  the  os 
uteri  be  sufficiently  dilated. 

When  the  hip  descends  should  you  be  careful  to  as- 
certain whether  it  rotates  ?  Although  rotation  of  the 
hip  is  of  less  importance  than  that  of  the  occiput,  yet 
it  is  proper  that  you  should  secure  the  rotation  of  the 
hip  as  it  passes  through  the  pelvis. 

Should  you  use  any  traction  effort  on  the  child  at 
this  time  ?  None  whatever  ;  it  would  be  generally 
safer  for  you  to  retard  the  descent  of  the  child,  that 
the  OS  uteri  may  become  freely  dilated. 

Should  you  support  the  perinseum  at  this  period  ? 
You  should  ;  not  so  much  however  to  prevent  its  being 
lacerated  as  by  this  means  to  delay  the  descent  of  the 
child. 

Should  you  do  any  thing  more  than  to  support  the 
child,  and  the  perinaeum  at  this  time  ?  Nothing  more 
than  this ;  no  traction  should  be  made  on  any  part  of 
the  child,  unless  it  be  to  assist  rotation. 

What  duty  devolves  upon  the  practitioner  in  con- 
ducting a  labor  in  which  the  feet  or  knees  present  ? 
Those  which  are  similar  to  what  is  required  in  the 
management  of  breech  presentations,  taking  care  in 
every  variety  of  such  presentations  not  to  interfere 
Avith  any  portion  of  the  child  which  is  in  utero,  unless 
there  be  some  mechanical  embarrassment  to  its  de- 
livery. 

What  is  an  important  rule,  in  reference  to  feet 
cases  ?  Not  to  facilitate  the  descent  of  the  feet  until 
the  first  stage  is  completed. 

Suppose  the  heels  of  the  child  are  situated  in  con- 
tact with  the  breech,  should  you  pull  down  the  feet  ? 
No ;  you  should  retard  the  delivery  in  the  first  stage, 
keeping  up  the  feet,  to  allow  the  breech,  &c.,  to  de- 
scend and  dilate  all  the  soft  parts. 


LABOR — DUTIES  OF  PHYSICIAN  AND  NURSE.      187 


MEDICINE  AND  SURGERY  OF  THE  LYING-IN-CHAMBER. 

Of  what  principles  of  the  healing  art,  is  the  prac- 
titioner of  midwifery  to  avail  himself,  in  the  manage- 
ment of  difficult  labors  ?  Both  medical  and  surgical 
principles,  viz. :  those  which  are  strictly  medical,  by 
which  he  is  to  overcome  difficulties  by  the  use  of 
agents  generally  administered  internally;  and  those 
which  are  strictly  surgical,  i.  e.  manual  or  instrumental ; 
in  which  the  obstacle  is  overcome,  or  aid  rendered 
by  the  hand  alone,  or  by  the  hand  and  appropriate 
instruments. 

What  circumstances  may  complicate  labor,  and 
render  medical  or  surgical  aid,  or  both,  necessary  ? 
Rigidity  of  the  os  uteri,  or  of  the  external  organs,  or 
of  both;  hemorrhage  from  some  part  of  the  body, 
particularly  from  the  uterus ;  convulsive  movements 
of  the  nervous  and  muscular  systems  ;  inertia 
of  the  uterus,  &c. ;  mal-positions  of  the  fetus ;  de- 
formities of  the  pelvis ;  the  existence  of  tumors  withiu 
it,  &c. 

What  has  the  accoucheur  to  do  in  these  cases  ?  To 
temporize  and  use  medical  means  in  the  cases  of 
rigidity,  but  he  must  use  the  hands  or  instruments,  or 
both,  in  the  other  varieties  of  complications. 

What  is  the  character  of  the  medical  means  to  be 
used  ?  Such  as  overcome  rigidity  when  it  exists,  and 
such  as  stimulate  the  uterus  when  necessary. 

What  is  the  character  of  the  surgical  means  to  be 
used  ?  That  which  modifies  the  position,  or  presenta- 
tion of  the  child,  or  expedites  the  delivery  of  it  and 
the  placenta,  when  necessary,  and  that  which  pre- 
vents or  corrects  accidents  to  the  woman  and  child. 

What  are  the  operations  by  the  hand  called  ?  Ma- 
noeuvres or  manipulations. 

What  complications  of  labor  require  the  use  of  the 
hand  to  aid  in  its  termination  ?  Those  in  which  there 
are  deviations  of  position:  and  those  in  which  hemor- 
rhage, or  convulsions  occur. 


188  MEDICINE   AND    SURGERY 

What  function  docs  the  hand  usually  perform  ? 
The  correction  of  the  presentation  or  position;  ver- 
sion, &c. 

HOW  TO  ASSIST  FLEXION. 

Under  what  circumstances  may  you  facilitate  the 
progress  of  the  head  through  the  pelvis  ?  Provided 
flexion  is  not  complete,  you  may  apply  the  finger 
against  the  side  of  the  forehead,  (not  on  the  fonta- 
nelle,)  and  pushing  it  up,  facilitate  the  flexion. 

Which  finger  should  be  used  ?  The  index  of 
the  left  hand,  for  the  first  and  fifth  positions,  and 
that  of  the  right  hand  for  the  second  and  fourth 
positions,  especially  if  the  patient  be  on  her  back. 

Is  this  the  only  manner  in  which  you  can  accom- 
plish this  flexion  ?  In  some  cases  it  may  be  even  bet- 
ter to  apply  one  or  two  fingers  to  the  occiput  with 
a  view  to  bring  it  down. 

Would  you  then  employ  the  same  fingers?  It  would 
then  be  more  convenient  and  eff"ective  to  use  those  of 
the  right  hand  in  the  first  and  fifth,  and  those  of  the 
left  hand  in  the  second  and  fourth  positions,  while 
the  patient  remains  on  her  left  side. 

VECTIS  OR  LEVER. 

Could  any  instrumental  means  be  brought  to  aid 
or  substitute  the  hand  for  assisting  flexion,  and  rota- 
tion ?  The  vectis  or  lever  has  for  many  years  been 
employed  to  aid,  or  substitute  the  hand  in  changing 
deviated  positions  of  the  head. 

What  kind  of  instrument  is  the  obstetric  lever,  or 
vectis  ?  It  is  intended  mainly  as  a  substitute  for  the 
better  action  of  a  single  hand,  whenever  that  hand 
cannot  be  well  applied  to  the  parts  upon  which  the 
change  is  to  be  effected. 

What  is  the  usual  form  of  the  vectis  ?  Although 
since  the  days  of  Roonhuysen,  the  supposed  inventor, 
in  the  early  part  of  the  eighteenth  century,  the  vec- 
tis has  undergone  many  modifications  in  form,  and  pro- 


OF  THE   LYING-IN   CHAMBEIl. 


189 


bably  also  in  the  mode  of  use,  that  commonly  pre- 
ferred at  present  is  represented  in 

Fig.  72. 


The  whole  instrument  is  twelve  inches  long ;  the 
handle  four  and  a  half,  the  rounded  part  of  the  shank 
is  two  and  a  half  inches,  while  the  expanded  and 
concavo-convex  clam  occupies  the  remaining  five 
inches. 

There  are  still  to  be  found  in  the  hands  of  some 
practitioners  the  vectis  with  a  clam  at  each  end,  one 
of  these  clams  is  usually  smaller  than  the  other,  for 
introduction,  in  some  cases,  in  which  the  pelvis  is 
contracted,  or  for  the  purpose  of  disengaging  a  pes- 
sary from  the  vagina.     This  form  is  shown  in 

Fig.  73. 


The  original  frona  which  the  drawing  was  made 
measures  ten  inches. 

MANNER  OF  USING  THE  VECTIS  OR  LEVER. 

What  is  the  correct  method  of  using  the  vectis  or 
lever  ?  The  first  principle  to  be  borne  in  mind  is 
that  the  concave  surface  of  the  instrument  is  to  be 
adapted  to  the  convex  surface  of  the  child's  head. 

What  is  probably  the  simplest  rule  for  the  hand  in 
which  it  is  to  be  held,  for  introducing  it  to  its  pro- 
per place  on  the  head  of  the  child  ?  It  will  be  most 
expedient  to  hold  it  in  that  hand  which  according  to  tho 


190  MEDICINE    AND   SURGERY 

rule  for  making  version  or  rotation  of  the  head,  is  not 
employed  in  the  vagina,  that  is,  since  in  the  first  and 
fifth  positions  of  the  occiput,  when  the  woman  is  on 
her  back,  it  is  expedient  to  pass  the  left  hand  into 
the  vagina  for  rectifying  deviation,  causing  rotation, 
or  assisting  flexion,  so  it  will  be  proper  in  these 
cases  to  hold  the  vectis  in  the  right  hand,  while  the 
left  is  used  as  a  guide  for  it  to  its  place,  and  the  op- 
posite hand  will  be  found  best  to  be  used  in  the 
second  and  fourth  positions. 

HOW  TO    EFFECT    ROTATION    OR    CONVERT   ONE    POSI- 
TION INTO  ANOTHER. 

How  should  you  assist  rotation,  if  the  fetus  require 
ti?  If,  in  the  first  position,  by  passing  the  index 
finger  of  the  right  hand  over  the  left  parietal  protu- 
berance, and  press  from  behind  forward ;  or  what  may 
be  better,  introduce  the  index  finger  of  the  left  hand, 
to  the  right  temple  of  the  child,  and  press  it  from 
above  downwards.  If  in  the  second  position,  the 
left  finger  is  to  be  used  on  the  right  parietal,  or  the 
right  on  the  left  temporal  bone.  If  in  the  fourth 
position,  with  a  view  to  facilitate  rotation  into  the 
hollow  of  the  sacrum,  the  left  index  finger  is  to  be 
applied  to  the  left  parietal  bone,  or  the  right  to  the 
right  temporal  bone.  If  in  the  fifth  position,  to 
rotate  to  the  sacrum,  the  right  index  to  the  right 
parietal  bone,  or  the  left  index  ^o  the  left  temporal 
bone. 

Suppose  you  are  not  certain  of  your  diagnosis  at 
this  stage  of  the  labor  ?  Do  nothing  until  you  are 
certain  both  of  the  diagnosis,  and  indications. 

Should  you  attempt  to  convert  a  third,  into  a 
first  or  second  position  of  the  vertex  ?  Yes  ;  when- 
ever possible. 

Suppose  flexion  does  not  take  place,  how  could  you 
assist  it  ?  By  passing  one  or  more  fingers  up  under 
the  arch  of  the  pubes  and  applying  it  over  the  occi- 
put aad  drawing  it  down,  or  by  passing  up  two  fingers, 


OF   THE    LYING-IN   CnAMBER.  191 

one  oti  each  side  of  the  frontal  bones,  and  pressing 
them  backwards  and  upwards. 

When  you  find  some  difficulty  in  converting  the 
third  into  the  first  or  second,  how  should  you  pro- 
ceed? Pass  in  the  hand,  and  carry  up  the  whole 
head  during  the  absence  of  pain  and  then  convert  it. 

In  reference  to  the  first  or  second  position,  how 
far  back  may  the  occiput  be,  to  justify  our  consider- 
ing it  still  a  first  or  second  position  ?  Yery  far 
back  when  still  high  in  the  pelvis. 

Are  transverse,  or  occipito-iliac  positions  rare? 
They  so  rarely  occur,  as  not  to  have  a  place  in  most 
systems  of  midwifery. 

Does  the  occiput  or  the  vertex  enter  the  superior 
strait  readily  in  the  posterior  varieties  ?  It  usually 
enters  the  superior  strait,  more  readily  than  when  it 
is  anterior. 

What  is  the  usual  difficulty  in  the  case  in  the  course 
of  the  labor  ?  That  of  getting  the  flexion  to  take 
place,  to  a  sufficient  degree. 

How  should  you  assist  the  flexion  ?  By  pressing 
against  the  forehead,  or  by  passing  a  finger  into  the 
rectum,  and  drawing  the  occiput  forward  if  it  cannot 
be  reached  through  the  vagina. 

Why  is  the  peringeum  in  greater  danger  in  this  than 
in  other  cases  ?  The  occiput  is  applied  to  it  with 
more  force  because  of  the  increased  size  of  the  cir- 
cumference of  the  head. 

What  do  some  scientific  and  experienced  accou- 
cheurs think  a  good  rule  in  all  cases  of  occipito-poste- 
rior  position,  if  diagnosticated  early  ?  Always  to 
direct  the  occiput  toward  the  anterior  part  of  the  pel- 
vis, which  must  pass  through  it  in  such  cases. 

•  How  would  you  convert  a  fourth  into  a  second  posi- 
tion ?  By  pressing  against  the  pubal  side  of  the  face 
with  a  finger  of  the  right  hand,  or  upon  the  sacral 
side  of  the  occipital  and  parietal  bone  with  the  fingers 
of  the  left  hand. 

How  would  you  convert  a  fifth  into  a  first  position  ? 


192  MEDICINE   AND    SURGERY 

By  pressing  against  the  face,  temple,  or  cheek;  or 
against  the  sacral  side  of  the  occiput  with  the  finger 
of  the  left  hand  in  the  first,  and  of  the  right  hand,  in 
the  second  instance. 

What  theoretical  objection  might  be  suggested 
against  this  practice  of  artificial  conversions  ?  That 
the  oblique  position  of  the  child  originally,  may  make 
it  necessary  that  the  neck  be  twisted  more  than  one- 
third  of  a  circle. 

What  is  the  result  of  experience  on  the  subject  ? 
That  no  injury  does  arise  from  the  practice. 

What  conversions  should  you  make  of  the  sixth 
position  ?  Into  a  fourth  or  fifth  position ;  this  con- 
version is  sometimes  spontaneous. 

What  should  you  do  with  the  occipito-left,  and 
occipito-right  iliac,  or  left  and  right  transverse  posi- 
tions ?  Always  strive  to  favor  the  conversion  of  the 
first  into  an  occipito-left,  and  the  second  into  an  occi- 
pito-right acetabular  position. 

VERSION  BY  THE  HEAD. 

What  do  you  mean  by  version  by  the  head  ?  That 
movement  by  which  the  head  is  restored  from  a  devi- 
ated to  a  proper  position. 

What  is  meant  by  version  by  the  vertex  ?  That 
movement  by  which  a  deviation  of  a  vertex  presenta- 
tion is  corrected,  or  reconverted  to  a  true  and  favor- 
able vertex  presentation.  This  term  applies  especially  to 
the  correction  of  deviated  positions  of  the  head  simply, 
while  version  by  the  head,  usually  means  the  bringing 
of  the  head  to  the  axis  of  the  pelvis  when  some  other 
part  of  the  child  has  been  presenting. 

What  is  the  rule  in  reference  to  the  hand  which 
must  be  used  ?  That  which  corresponds  in  name  to 
the  name  of  the  side  to  which  the  occiput  presents. 

DIFFERENT  STEPS  OF  THE  PROCESS. 

What  are  the  different  steps  of  the  operation? 
First,  lubrication  of  the  hand  and  soft  parts ;  next, 


OF   THE    LYING-IN    CHAMBER.  193 

the  dilatation  of  the  genital  fissure  and  vagina;  then 
the  passage  of  the  hand  into  the  os  uteri ;  next  the 
seizing  of  the  head ;  and  lastly,  its  version. 

How  are  you  to  dilate  the  vulva  ?  By  the  gradual 
introduction  of  the  hand  in  a  conical  shape,  with  the 
point  of  the  thumb  bedded  between  the  fingers. 

What  position  should  the  hand  be  in  ?  In  a  state 
of  semi — supination. 

What  is  this  movement  technically  called  ?  Intro- 
duction. 

In  what  condition  of  the  patient  are  you  to  make 
this  introduction  ?     During  a  pain. 

In  what  position  are  you  to  carry  the  hand  when 
introduced  ?     In  that  of  supination. 

What  general  direction  are  the  thumb  and  fingers 
to  assume  ?  Thumb  towards  the  face,  fingers  towards 
the  occiput. 

In  what  condition  of  the  patient  are  you  to  make 
the  rest  of  the  manoeuvre  ?     In  the  absence  of  a  pain. 

How  do  you  seize  the  head  ?  First,  place  your 
hand  against  the  presenting  part,  push  it  up  in  the  axis 
of  the  superior  strait,  and  slide  your  hand  under  it  to 
beyond  the  middle  line  of  the  occiput — then  embrace 
the  head,  extend  the  thumb  on  the  sinciput,  and  carry 
the  chin  over  to  the  iliac  fossa,  opposite  to  that  in 
which  the  occiput  is  situated ;  then  let  it  descend. 

How  should  the  other  hand  be  employed  at  this 
time  ?  It  should  be  applied  over  the  fundus  of  the 
uterus,  to  support  it  properly. 

What  are  the  objections  to  this  version  by  the 
head  ?     The  difficulty  of  seizing  the  head. 

PRESENTATIONS   OF  THE  ANTERIOR  FONTANELLE. 

Do  cases  of  presentations  of  the  anterior  fonta- 
nelle,  to  the  centre  of  the  pelvis,  ever  occur  in  prac- 
tice ?     They  are  sometimes  met  with. 

How  does  this  happen  ?  In  consequence  of  the 
head  being  carried  down  in  a  state  of  extension  in- 
stead of  flexion. 

17 


194  MEDrCINE    AND    SIRGERT 

What  diameters  present  to  the  pelvis  in  this  case  ? 
The  occipito-frontal,  and  bi-parietal  diameters. 

What  diameter  corresponds  with  the  axis  of  the 
superior  strait  ?     The  trachelo-bregmatic  diameter. 

Does  this  deviation  ever  become  spontaneously  cor- 
rected as  it  descends  ?  It  is  believed  that  it  might  be 
hazardous  to  rely  upon  spontaneous  correction  of  this 
deviation,  though  this  may  possibly  occur. 

Suppose,  however,  the  occiput  becomes  arrested  at 
the  linea-ilio  pectinea,  what  is  the  consequence  ?  The 
head  becomes  locked  in  the  superior  strait,  cavity,  or 
inferior  strait  of  pelvis. 

Would  such  a  state  of  things  render  delivery  im- 
practicable ?  It  would,  unless  the  pelvis  be  very  large, 
or  the  head  very  small. 

What  practice  should  you  adopt  to  prevent  the  oc- 
currence of  this  difficulty,  if  you  see  the  patient 
early  ?  If  the  os  uteri  be  sufficiently  dilated,  to  en- 
able you  to  carry  up  one  or  two  fingers  sufficiently 
fiir,  you  may  push  up  the  forehead  and  let  the  occiput 
descend. 

Does  the  head,  when  so  deviated,  engage  less  readily 
in  the  superior  strait,  than  those  in  which  the  vertex 
presents  ?  There  are  two  causes  of  delay  in  the  de- 
scent of  the  head  in  deviations  of  this  kind ;  first, 
because  this  position  of  the  head  offers  a  larger  sur- 
face to  the  OS  uteri,  and  therefore  cannot  pass  through 
it  so  readily ;  secondly,  the  occipito-frontal  diameter 
cannot  readily  descend  in  the  superior  strait,  while 
the  thickness  of  the  walls  of  the  neck  of  the  uterus  is 
added  to  it.  ^ 

When  are  these  deviations  mostly  recognized  ? 
When  the  head  has  come  down  into  the  cavity  or  infe- 
rior strait  of  the  pelvis. 

What  indications  have  we  to  fulfill  when  the  head 
has  descended  into  the  inferior  strait  in  either  of  these 
positions  ?  The  movements  of  flexion,  and  if  necessary, 
rotation. 

How  are  you  to  make  tlie  restitution  in  this  case  ? 


Oi'    THE    LYING-IN    CHAMBER.  195 

Pass  up  your  finger,  and  arrest  the  descent  of 
the  head  until  the  occiput  comes  down,  or  act  on 
the  side  of  the  forehead  with  the  fingers  of  the  ap- 
propriate hand. 

If  the  fingers  do  not  succeed,  what  would  be  the 
next  best  step  of  procedure  ?  If  there  be  room,  pass 
up  the  entire  hand  into  the  pelvis,  and  then-  seize  the 
head  to  carry  its  chin  up  to  the  thorax,  and  let  the 
occiput  descend. 

Is  it  indifferent  which  hand  is  used  in  these  cases  ? 
By  no  means,  since  to  provide  against  embarrassment 
in  this  operation  as  much  as  possible,  it  will  be  found 
best  always  to  use  the  hand  of  which  the  palm  would 
always  readily  look  toward  the  face  of  the  child — 
thus  if  the  woman  were  lying  on  her  back,  and  the 
deviation  was  from  the  first,  or  occipito-left  acetabular 
position,  the  left  hand  should  be  used — also  in  similar 
deviations  from  the  fifth  position — while  in  deviations 
from  the  second  and  fourth  positions,  the  right  hand 
should  be  used. 

What  is  the  manner  of  direction  of  either  hand  to 
be  used  ?  First,  compress  the  fingers  into  a  conical 
form,  then  during  a  pain  pass  it  entirely  within  the 
vulva  till  the  points  of  the  fingers  touch  the  child's 
head ;  next,  as  soon  as  the  contraction  subsides,  pass 
the  fingers  around  the  sacral  side  of  the  head,  fairly 
upon  the  occiput,  spreading  the  thumb  at  the  same 
time  upon  the  sinciput,  as  far  as  possible  towards  the 
forehead,  carry  the  head  so  embraced,  a  little  way,  if 
possible,  clear  of  the  superior  strait,  and  at  the  next 
moment,  by  an  adducting  motion  of  the  hand  upon 
the  wrist  carry  up  the  mental  and  depress  the  occipi- 
tal pole  of  the  head — retain  it  in  this  position  till  a 
contraction  forces  down  the  head  with  the  occiput 
fairly  on  one  of  the  inclined  planes. 

What  should  the  introduced  hand  perform  at  the 
same  time,  if  the  occiput  be  posterior  ?  So  rotate  it 
as  to  cause  it  to  engage  on  one  of  the  anterior  inclined 
planes. 


196  MEDICINE   AND    SUllGERY 

How  should  the  other  hand  he  employed  at  the 
same  time  ?  In  giving  proper  support  to  the  uterus 
by  being  expanded  on  the  abdomen  over  the  fundus 
of  the  uterus,  and  assisting  to  correct  a  right  or  left 
lateral  obliquity  if  any  exists. 

TRY  TO  USE  THE  LEVER. 

Suppose  you  cannot  succeed  with  your  fingers  or 
hand,  what  should  you  do  ?  Try  to  fix  the  lever  upon 
the  occiput,  and  pressing  up  the  forehead  with  the 
finger,  bring  down  the  occiput. 

Should  you  do  this  in  the  absence  of  a  pain? 
This  is  the  only  time  in  which  you  could  expect  to 
succeed. 

If  the  head  descend  into  the  cavity,  how  should  you 
manage  it  ?  Pass  in  your  lever  under  the  sacral  side 
of  the  occiput,  and  effect  flexion  and  rotation  at  the 
same  time. 

Suppose  the  head  has  descended  into  the  inferior 
strait,  how  should  you  do  ?  It  is  desirable  still  to 
make  restitution  if  possible,  and  bring  the  occipito- 
mental diameter  into  relation  with  the  axis  of  the  pel- 
vis, and  with  this  view  it  has  been  proposed  to  pass 
one  or  two  fingers  into  the  anus,  and  press  the  head 
through  the  recto-vaginal  wall,  into  its  proper  relation 
with  the  pelvis,  and  then  let  it  come  down. 

OBLIQUITY  OF    THE    UTERUS— PROBABLE    CAUSE  OF 
DEVIATION. 

Do  the  obliquities  of  the  uterus  probably  ever  con- 
tribute to  cause  these  deviations  ?  It  is  believed  that 
they  do. 

Is  the  head  in  these  deviations  more  likely  to  be 
arrested  in  the  third,  than  in  other  anterior  varie- 
ties ?    This  opinion  is  entertained  by  some  accoucheurs. 

What  practice  should  be  resorted  to,  to  correct  the 
deviation  in  these  cases  ?  Push  up  the  head,  rotate 
it  partially,  push  up  the  forehead  and  allow  the  occiput 
to  descend. 


OF   THE    LYING-IN    CHAMBER.  197 

Can  you  use  the  lever  to  any  advantage  ?  Yes,  if 
properly  applied,  you  may  effect  both  flexion  and  ro- 
tation with  it  and  the  fingers. 

Is  this  a  proper  case  for  the  forceps  ?  No,  not 
while  the  deviation  continues. 

When  the  deviation  takes  place  to  a  still  greater 
extent,  what  kind  of  presentation  have  we  ?  Presen- 
tation of  the  face. 

PRESENTATION    OF  THE    FACE. 

What  diameters  present  to  the  pelvis  in  face  presen- 
tations ?  The  fronto-mental  and  bi-malar,  apparently 
— though  really,  the  trachelo-bregmatic  and  bi -parie- 
tal diameters,  when  the  chin  presents  or  rotates  ante- 
riorly. 

What  part  presents  to  the  centre  of  the  pelvis  ? 
The  root  of  the  nose. 

Fig.  74. 


Does  much  embarrassment  occur  in  all  cases  of  face 
presentation  ?     It  does  so  when  the  sinciput  is  ante- 
rior in  consequence  of  the  occiput  being  thrown  back- 
^-ards  upon  the  spine  of  the  child. 
17* 


198 


MEDICINE   AND    SURGERY 


Fig.  75. 


Is  delivery  impracticable  in  that  case  ?  It  is 
nearly  always  so,  if  the  child  has  its  usual  proportions. 
Suppose  the  chin  presents  to  the  anterior  parts  of 
the  pelvis,  is  delivery  equally  impracticable  ?  Spon- 
taneous delivery  is  practicable,  and  the  child  may  be 
readily  born  alive. 

What  is  the  reason  of  this, 
since  in  all  other  cases  of  dor- 
sum of  the  child  to  the  spine 
of  the  mother  is  regarded 
less  favorable  than  when  the 
dorsum  is  anterior  ?  In  this 
case  it  is  true,  there  are 
many  inconveniencies ;  but 
as  the  chin  descends  near- 
ly in  the  axis  of  the  pel- 
vis, the  sinciput  is  accom- 
modated in  the  hollow  of  the 
sacrum,  the  trachelo-bregma- 
tic  diameter  nearly  corres- 
ponds to  the  occipito  breg- 
matic  diameter  as  in  cases  of 
original  occipital  presentation ;  as  the  head  descends, 
the  chin  appears  under  the  arch,  while  the  front  part 
of  the  neck  is  forced  strongly  against  the  posterior 
part  of  the  p.ubes,  and  this  part  of  the  throat  becomes 
as  it  were,  the  centre  of  motion  as  the  head  is  driven 
forward ;  to  have  first  the  chin,  next  the  face,  then 
the  forehead,  and  lastly  the  sinciput,  pass  successively 
over  the  perinseum.  In  consequence  of  the  small 
depth  of  the  pelvis  at  the  symphysis,  the  back  part 
of  the  head  and  the  top  of  the  thorax,  are  less  forci- 
bly engaged  in  the  superior  strait  at  the  same  time 
in  this  case,  as  must  happen  in  the  case  of  those  po- 
sitions in  which  the  bregma  comes  under  the  arch  of 
the  pubes,  (fig.  77.) 

Are  the  face  presentations  to  be  regarded  as  ren- 
dering delivery  impracticable  ?  Not  when  the  chin 
rotates  under  the  arch  of  the  pubes. 


or   THE   LYING-IN   CHAMBER. 


199 


Fig.  76. 


Can  the  face  enter  the  superior  strait  when  the 
chin  presents  to  the  sacrum  of  the  mother  ?  It 
can  enter  the  superior  strait 
without  much,  if  any  difl5- 
cultj. 

What  obstacle  offers  to 
the  delivery  of  these  cases? 
When  the  chin  is  turned  to- 
wards the  sacrum,  it  may 
be  said  that  we  have  the 
occipito-bregmatic  diameter 
of  the  head,  and  the  dor- 
so-sternal  diameter  of  the 
upper  part  of  the  thorax, 
attempting  to  pass  down 
into  the  space  of  the  sacro- 
pubal  diameter  of  the  pelvis. 
Under  such  circumstances,  it  is  impossible  for  the 
occipito-mental  diameter  of  the  head  to  come  into 
correspondence  with  the  axis  of  the  pelvis ;  the  con- 
vexity of  the  sinciput  is  constantly  applied  to  that 

Fig.  77, 


of  the  inner  side  of  the   sjmiphysis  pubes,  while  the 
concavity  of  the  mental,  tracheal  and  thoracic  surface  ; 


200 


MEDICINE   AND    SURGERY 


SO  to  speak,  is  opposed  to  the  cavity  of  the  posterior 
portion  of  the  sacrum.  Hence  the  capacity  of  the 
pelvis  is  insufficient  for  the  transmission  of  the  head 
and  shoulders  of  the  fetus  in  this  direction,  by  the 
uterine  and  voluntary  powers  of  the  mother  alone,  and 
scarcely  ever  by  the  use  of  the  forceps. 

CLASSIFICATION  OF  FACE  PRESENTATIONS. 

How  many  varieties  or  positions  of  face  presenta- 
tions are  recognized  by  systematic  writers  ?  Usually 
the  same  number  as  in  occipital  presentations. 

What  are  the  most  common  varieties  of  face  pre- 
sentations ?  Presentations  of  the  face  are  nearly  al- 
ways resolved  into  right  mento-iliac  and  left  mento- 
iliac,  by  the  time  the  face  gets  into  the  cavity  of  the 
pelvis. 

Can  the  labor  in  these  cases  be  terminated  spon- 
taneously, or  with  slight  assistance  ?  They  can  pro- 
vided the  chin  comes  under  the  arch  of  the  pubes. 

Fig.  78. 


What  is  the  mechanism  of  labor  in  these  cases  ? 
First,  the  extension  becomes  as  great  as  possible — 
the  face  is  then  carried  down,  the  chin  rotates  upon 


OF   THE    LYING-IN   CHAMBER.  201 

the  anterior  plane,  until  it  gets  under  the  arch  of  the 
pubes :  flexion  then  takes  place  until  the  head  clears 
the  perin?eum,  and  the  labor  terminates  as  in  an 
occipito-posterior  position. 

Does  flexion  take  place  at  any  time  during  labor 
with  face  presentation,  chin  forwards  ?  Not  at  all, 
until  the  chin  comes  under  the  arch  of  the  pubes. 

Should  you  in  all  cases  endeavor  to  assist  the 
rotation  of  the  chin  under  the  arch  ?  Always,  if 
possible. 

What  should  you  do  if  you  find  the  child  descend- 
ing face  foremost  at  the  superior  strait  ?  Ey  the  old 
rule,  we  should  make  version  by  the  feet,  but  under 
the  counsel  of  more  scientific  instruction,  we  should 
perform  version  by  the  head,  and  bring  down  the 
vertex,  if  the  chin  cannot  be  made  to  descend  on  an 
anterior  inclined  plane  to  the  symphysis  pubes. 

Suppose  a  manipulation  of  this  kind  to  be  admissi- 
ble, that  is,  the  head  still  high  up  and  easily  move- 
able above  the  superior  strait,  in  what  direction 
should  you  attempt  to  bring  down  the  occiput  ?  Al- 
ways at  first  into  that  opposite  to  that  in  which  the 
chin  was  situated,  after  which  you  must  efiect  rotation 
if  necessary,  as  already  stated. 

Suppose  the  second  stage  of  labor  be  complete,  and 
the  face  have  descended  into  the  cavity  of  the  pelvis^ 
how  should  you  act  ?  Endeavor  to  rotate  the  chin  to- 
wards the  arch  of  the  pubes. 

Can  much  be  done  by  the  use  of  your  fingers,  if 
you  well  understand  the  mechanism  of  labor?  Much 
may  be  done  by  these  means  at  various  degrees  of  the 
progress  of  labor,  if  its  mechanism  be  well  under- 
stood, and  the  accoucheur  use  his  fingers  dexterously 
and  cautiously. 

Suppose  you  find  the  top  of  the  head  coming  un- 
der the  arch  of  the  pubes,  and  you  cannot  rotate  it, 
what  instruments  may  you  apply?  The  forceps,  Avith 
the  hope  of  effecting  delivery  ultimately. 

Does  the  introduction  of  these  instruments  require 


202  MEDICINE   AND    SURGERY 

any  particular  care  in  these  cases  ?  Great  care  is 
necessary,  as  you  are  obliged  to  depress  the  handles, 
and  at  the  same  time  apply  the  ends  of  the  blades 
high  above  the  pubes,  and  more  or  less  against  the 
shoulders  of  the  child. 

What  instruments  are  indicated  in  cases  the  forceps 
cannot  deliver  ?  Perforator  and  crotchet,  &c.,  or 
after  the  perforator  and  the  collapse  of  the  cranium, 
the  cranotomy  forceps  of  Dr.  Meigs. 

CASES  PROPER  TO  BE   CONVERTED  INTO   FACE  PRESEN- 
TATION. 

What  deviations  may  we  convert  with  advantage 
into  face  presentations  ?  ,  Those  in  which  the  fore- 
head presents,  and  cannot  be  rectified  by  restoration 
to  an  occipital  or  vertex  presentation. 

What  objections  to  this  practice  when  the  occiput 
is  anterior  ?  They  would  then  be  converted  into  a 
case  of  impracticable  labor  with  the  face  presenta- 
tion, unless  rotation  could  be  effected  by  dexterous 
manipulation. 

Should  you  ever  allow  a  forehead  presentation  to 
continue  as  such  when  you  discover  it  to  exist  ? 
Never,  if  possible  to  correct  it  by  reduction  to  an 
occipital  presentation,  or  an  antero-mental  presen- 
tation. 

What  should  be  your  rule  of  action  in  these  cases  ? 
To  convert  the  fronto-anterior  position  into  the  chin 
presentation,  and  to  attempt  to  bring  down  the  occi- 
put, when  they  are  sincipito-anterior. 

VERSION  BY  THE  FEET. 

What  is  meant  by  version  by  the  feet  ?  That  ope- 
ration by  which  the  hand  is  introduced  into  the  ute- 
rus, and  the  feet  seized  and  brought  down  by  it. 

Which  variety  of  version  is  most  common  in  this 
country  ?     Perhaps  version  by  the  feet. 

Which  is  to  be  preferred,  when  either  version  by 
the  head,  or  by  the  feet,  is  accomplishable  ?    That  by 


OF   THE    LYIXG-IX    CIIAMBETl.  203 

the  head  by  far,  as  the  subsequent  delivery  is  more 
natural  and  safe. 

What  inconveniences  does  the  mother  usually  suffer 
from  an  effort  by  the  accoucheur  to  make  version 
by  the  feet  ?  Pain,  risk  of  hemorrhage  and  the  rup- 
ture of  the  uterus,  or  other  injury  to  it. 

To  what  risks  is  the  child  subject,  in  version  by  the 
feet  ?  It  may  suffer  from  being  too  severely  twisted 
upon  its  spine ;  and  also,  all  the  inconvenience  of 
original  feet  or  breech  presentations. 

Is  version  by  the  head  or  feet,  to  be  resorted  to 
with  a  great  deal  of  care  ?  It  must  so,  and  with 
calculation  of  the  capability  of  the  mother  to  bear  it. 

Should  you  obtain  a  consultation  on  the  propriety 
of  it,  if  possible  ?  You  should,  w^henever  it  is  prac- 
ticable without  hazardous  delay. 

CONDITION  OF  THE  MOTHER  F^iVORABLE  TO  VERSION. 

What  condition  of  the  os  uteri  must  exist  before  it 
will  be  admissible  to  perform  version  ?  That  of  dila- 
tion, or  facility  of  dilation. 

What  are  you  to  do  until  this  state  of  the  os  uteri 
is  obtained  ?  Temporize  by  using  proper  medical 
treatment  if  any  be  indicated. 

ONLY  WHILE  THE  HEAD  IS  WITHIN  THE  OS  UTERL 

Is  it  admissible  to  make  version  after  the  head  has 
passed  the  os  uteri  ?  Never  ;  you  should  operate  as 
soon  as  possible  after  the  first  stage  is  completed. 

What  dangers  attend  any  attempt  at  this  opera- 
tion under  such  circumstances,  that  is,  when  the 
head  has  been  driven  out  of  the  uterus  ?  The  ute- 
rus may  be  ruptured,  and  the  soft  parts  within  the 
pelvis  may  be  injured ;  the  child's  head  may  also  be 
wounded. 

OPERATION. 

At  what  moment  can  you  proceed  to  this  opera- 
tion  with   the  best  effect  ?      Directly  that    the  first 


204  MEDICINE    AND    SURCERY 

stage  of  labor  is  complete,  or  the  os  uteri  suffi- 
ciently dilated  to  admit  the  passage  of  the  hand  and 
arm. 

POSITION  OF  PATIENT  PROPER  FOR  IT. 

What  position  should  the  patient  be  placed  in  for 
the  purpose  of  making  version  by  the  feet  ?  On  her 
back,  with  her  hips  over  the  edge  of  the  bed,  and 
her  feet  properly  supported. 

Why  would  you  have  her  brought  to  the  edge  of 
the  bed  ?  To  allow  room  for  the  ready  move- 
ments of  the  accoucheur  in  introducing  his  hand  and 
part  of  his  arm  and  completing  the  manoeuvre. 

How  should  the  patient's  feet  be  disposed  of? 
They  should  be  placed  out  on  chairs  or  any  conve- 
nient staging  which  may  enable  her  to  keep  them  on 
a  level  with  her  hips. 

POSITION  OF  THE  ACCOUCHEUR. 

What  position  is  the  accoucheur  to  assume  for  the 
purpose  of  passing  the  hand  ?  One  in  front  of  the 
patient  and  which  is  most  easy  to  himself. 

What  attention  should  be  given  to  the  dress  of  his 
person,  to  prepare  for  this  purpose  ?  He  should  lay 
off  his  tight  coat,  roll  up  his  shirt-sleeves,  then  put  on 
a  wrapper,  or  some  other  loose  cover,  with  as  little 
display  as  possible. 

How  are  the  parts  of  the  patient  to  be  prepared  ? 
They  should  be  well  lubricated  with  some  mucilage, 
oil,  or  lard. 

What  calculation  has  the  operator  to  make  previ- 
ously to  passing  the  hand  ?  That  by  which  he  de- 
termines what  is  the  position  of  the  different  parts 
of  the  child,  what  alteration  he  has  to  make,  and 
which  hand  he  must  use  to  eifect  this  object. 

RULE  FOR  THE  USE  OF  THE  PARTICULAR  HAND. 

What  is  the  rule  for  the  use  of  the  particular  hand 
in  version  of  the  feet  ?     Use  that  hand,  the  palm  of 


OF  THE   LYING-IN   CHAMBER.  205 

which  would  correspond  to  the  abdomen  of  the  child, 
and  which  in  withdrawing  it,  having  hold  of  the  feet, 
will  keep  the  body  in  a  state  of  flexion  during  the 
whole  process  of  the  version,  or  till  the  limbs  and 
body  are  withdrawn  from  the  uterus. 

How  are  you  to  proceed  to  make  the  version  by 
the  feet  ?  First,  introduce  the  hand  properly  during 
a  pain ;  next,  press  up  the  head,  and  pass  the  palm 
of  the  hand  along  the  front  and  on  one  side  of  the 
child,  over  the  whole  body  to  the  breech,  then  cause 
it  to  descend  upon  the  thighs  and  legs,  and  next  em- 
brace the  feet,  retain  these  in  the  hollow  of  the  hand 
until  they  are  brought  down  into  one  iliac  fossa,  or 
into  the  cavity  of  the  pelvis ;  then  slip  the  index 
finger  between  them,  retaining  the  heels  in  the  palm 
of  the  hand,  until  they  are  completely  beyond  the 
vulva.     Fig.  79. 

Fig.  79. 


Can  you  always  seize  both  feet  in  this  case  ? 
Though  a  skilful  operator  can  mostly  do  so,  it  is  not 
always  practicable. 

How  must  you  act  if  you  have  but  one  foot  ?  Draw 

18 


206  MEDICINE   AND    SURGERY 

it  carefully  downward,  in  the  direction  of  the  axis  of 
the  pelvis,  at  the  same  time  adducting  it  towards  the 
other  as  much  as  possible. 

Fig.  80. 


How  can  you  secure  the  foot  drawn  out,  while  you 
search  for  the  other  ?  Pass  a  noose  of  a  soft  band 
or  fillet  upon  it,  and  let  the  loose  extremities  of  the 
fillet  remain  out  of  the  vulva. 

Is  it  always  necessary  to  reach  the  second  foot  ? 
It  is  neither  always  necessary  nor  proper  to  search 
for  this,  if  it  is  not  easily  found. 

What  rule  should  be  observed  in  reference  to  bring- 
ing the  back  part  of  the  feet  to  the  anterior  part  of 
the  pelvis  ?  Always  to  do  this,  because  of  the  much 
greatej  facility  of  subsequent  delivery  of  the  head. 

How  is  this  to  be  effected  ?  By  acting  upon  the 
pubal  leg  more  than  on  the  other. 

Into  what  position  of  the  feet  do  you  change  a  first 
cephalic  position  ?  To  the  second,  and  not  to  the 
fourth  position  of  the  feet. 

How  are  you  to  do  this  ?  By  acting  most  on  the 
pubal  leg,  and  abducting  it  from  the  other. 

Into  which  position  should  you  bring  the  feet, 
when  you  use  your  right  hand  for  version  ?  First 
position. 


OF   THE   LYING-IN    CHAMBER. 


207 


In  which  position  does  the  left  hand  bring  down 
the  feet  ?  Into  the  second  position  of  the  feet,  as 
seen  in  fig.  81. 

Fig.  81. 


WHEN  TO  ACT  ON  THE  BREECH  ONLY. 

Suppose  you  were  to  find  when  you  had  decided 
that  version  of  the  child  was  necessary,  that  the 
ovisac  had  been  ruptured,  the  waters  drained  off,  and 
the  uterus  was  pressing  on  the  fetus,  by  powerful 
tonic  contractions,  would  you  deem  it  expedient  to 
overcome  this  resistance  by  a  forcible  attempt  to  un- 
fold the  feet,  at  the  risk  of  increasing  the  transverse 
diameter  of  the  excited  organ,  at  least  three  inches  ? 
The  propriety  of  such  a  proceeding  would  be  at  least 
doubtful,  and  it  would  probably  be  more  appropriate 


208  MEDICINE   AND    SURGERY 

to  attempt  the  version  by  causing  the  hand  employed 
within  to  act  upon  the  breech  only,  while  the  hand 
without  should  by  a  well-directed  movement  aid  in 
causing  the  pelvic  pole  of  the  fetus  to  descend  to- 
wards the  pelvis  of  the  mother. 

WHAT  TO  DO  WITH  THE  CORD. 

What  should  you  do  when  you  have  delivered  the 
body  as  far  as  the  umbilicus  ?  Draw  out  a  fold  of  the 
cord  of  sufficient  length,  to  prevent  it  from  being 
ruptured,  as  shown  in 

Fig.  82. 


Is  it  necessary  for  you  to  continue  to  aid  the  deli- 
very of  the  child,  after  you  have  made  version  or 
mutation  ?  It  is  usually  necessary,  at  least  to  such 
an  extent  as  enables  you  to  assist  the  proper  rotation 
of  the  hips,  shoulders,  and  head. 

If  you  find  the  arms  do  not  descend  with  the  body 


OP  THE   LYING-IN   CHAMBER. 


209 


Fig.  83. 


of  the  child,  can  you  do  any  thing  to  encourage  their 
descent  ?  Suspend  the  tractive  effort,  resist  for  a  few 
moments,  the  descent  of  the  body,  and  let  the  uterus 
force  down  the  arms  if  possible. 

Suppose  however  this  does  not  occur,  how  are  you 
to  act  to  get  down  the  arms  ?  Carry  the  body  side- 
wise,  so  as  to  admit  of  the  introduction  of  the  fingers 
up  to  the  elbow,  and  bring  down  first  the  sacral,  and 
next  the  pubal  arm,  in  the  proper  direction  for  flexion 
at  the  elbow. 

Is  there  any  rule  as  to 
the  hand,  which  should  be 
used  in  bringing  down  the 
shoulders  ?  It  will  be  found 
more  convenient,  and  is 
certainly  more  appropriate 
to  use  the  right  hand  for 
bringing  down  the  right 
shoulder,  and  vice  versa. 

In  what  way  can  you 
best  adapt  the  hand  to 
cause  it  to  occupy  the 
least  possible  space,  while 
performing  this  part  of 
the  operation?  Spread  the 
palm  upon  the  scapular 
and  the  axillary  space  of 
the  thorax,  so  that  the 
thumb  will  be  directed  to- 
wards the  vertebral  co- 
lumn, while  one  or  two  fingers  are  spread  upon  the 
humerus,  to  be  flexed  as  soon  as  their  points  reach 
the  middle  joint  of  the  arm. 

Which  way  are  you  to  direct  the  movements  of  the 
arm  ?  Always  over  the  anterior  portions  of  the  child's 
head,  thorax,  and  abdomen. 

Suppose  the  arms  are  locked  behind  the  occiput  of 
the  child,  how  would  you  disengage  them  ?  .  Press  up 
the  head  during  the  absence  of  a  pain,  and  with  the 
18* 


210 


MEDICINE   AND   SURGERY 


points  of  your  finger,  carry  the  elbow  over  the  side 
of  the  head  and  face,  and  then  over  the  thorax.  If 
you  cannot  succeed  with  your  fingers,  use  the  blunt 
hook,  as  a  lever  for  this  purpose. 

If  the  trunk  and  arms  be  thus  delivered,  and 
the  head  is  found  to  be  arrested  in  the  pelvis, 
what  steps  should  be  taken  to  secure  its  speedy  de- 
livery ?  Reposing  the  body  of  the  child  on  an  arm, 
quickly  but  dexterously,  insert  one  or  more  fingers, 
over  the  chin  of  the  child  to  its  mouth,  upon  this 
draw  till  the  head  is  disengaged,  or  till  the  chin  de- 
scends as  far  as  possible  upon  the  neck  or  thorax ;  if 
this  does  not  succeed  in  a  very  short  time,  pass  two 
fingers  upon  the  zygomatic  processes  of  the  malar 
bones,  and  draw  down  forcibly,  while  with  one  or 
more  fingers  of  the  other  hand  push  up  the  occiput 
with  a  view  to  get  the  mento-occipital  diameter  of 
the  head  to  correspond  as  nearly  as  possible  with  the 
axis  of  the  pelvis,  as  seen  in  fig.  84. 

Fig.  84. 


What  other  benefit  might  accrue  to  the  child  if  the 
fingers  of  4he  accoucheur  were  skilfully  applied  upon 
its  face  in  case  the  delivery  of  the  head  could  not  be 


OF   THE   LYING-IN    CHAMBER.  211 

instantaneously  effected  ?  By  such  attentions  the 
child  is  often  enabled  to  respire  freely,  and  its  con- 
dition rendered  safe,  though  it,  the  mother,  and  the 
attendants  are  still  compelled  to  be  in  a  very  uncom- 
fortable situation. 

What  instrumental  aid  would  be  indicated  in  case 
of  failure  of  success  in  attempts  to  deliver  the  head 
by  the  hands  alone  ?  The  vectis  or  lever,  might  pos- 
sibly be  of  service  to  assist  in  getting  the  head  into 
proper  relations  with  the  maternal  pelvis,  but  the  for- 
ceps, and  possibly  the  perforator  also,  should  be  most 
relied  upon  if  the  extraction  could  not  afterwards  be 
effected  by  the  manual  exertions. 

SHOULDER  PRESENTATIONS. 

What  do  we  mean  by  shoulder  presentations  ?  They 
are  presentations  of  the  upper  parts  of  the  sides  of 
the  body,  and  are  probably  originally  deviations 
from  cephalic  presentations. 

Fig.  85. 


CLASSIFICATION  OF  SHOULDER  PRESENTATIONS. 

What  number  of  presentations  of  the  shoulders 
are  there?  Two  of  the  right  and  left  shoulders, 
each. 

What  points  of  the  mother  and  child,  do  we  take  in 


212  MEDICINE   AND    SURGEEY 

our  diagnosis?  The  pubis  and  the  sacrum  of  the 
mother,  and  the  dorsum  of  the  child. 

How  do  you  diagnosticate  the  shoulder  presenta- 
tions ?  By  the  presence  of  a  tumor,  on  one  side  of 
which  is  a  smooth  elastic  surface,  the  side  of  the  neck ; 
on  another  a  slender  bone,  the  clavicle ;  on  the  oppo- 
site side  a  broad  plate  of  bone,  the  scapula ;  between 
these  a  number  of  small  ridges,  the  ribs ;  mostly,  and 
more  important,  a  small  cylindrical  body,  an  arm,  ly- 
ing parallel  to  a  larger  one. 

What  is  the  value  of  the  hand  of  the  fetus  in  the 
diagnosis  of  shoulder  presentations  ?  It  may  assist 
considerably  in  making  up  the  diagnosis.  By  some 
practitioners  it  has  been  advised  to  bring  down  the  arm 
to  determine  the  position.  We  are  persuaded,  how- 
ever, that  this  practice  is  rarely  if  ever  necessary. 

Should  we  be  very  precise  in  our  calculation  of  the 
exact  relative  position  of  the  back  and  the  pelvis  ? 
As  it  probably  rarely  happens,  that  the  dorsum  of  the 
child  is  applied  to  the  pubes  with  as  much  accuracy  as 
the  occiput  is  to  the  left  acetabulum,  &c.,  we  have  to 
take,  as  a  general  statement,  the  nearest  approxima- 
tion to  it  in  our  practice. 

POSITIONS  OF  THE  SHOULDERS. 

What  are  the  positions  of  the  shoulders  ?  Dorso- 
pubic,  and  dorso-sacral,  of  the  right  and  of  the  left 
shoulders. 

Can  spontaneous  delivery  ever  take  place  in  cases 
of  shoulder  presentations  ?  Never  while  they  con- 
tinue as  shoulder  presentations,  provided  the  child  be 
at  or  near  the  term  of  its  development.  In  some  very 
rare  instances,  the  uterine  and  voluntary  contractions 
have  effected  such  mutations  in  the  position  of  the 
child  as  to  expel  it  with  one  of  the  extremities,  usually 
the  pelvic,  presenting. 


OF   THE   LYING-IN   CHAMBER. 


213 


SPONTANEOUS  VERSION. 

What  is  this  mutation  called  ?  Spontaneous  evolu- 
tion, or  spontaneous  version. 

What  is  to  be  understood  by  spontaneous  version  ? 
That  movement  by  which  the  body  of  the  child,  origi- 
nally unfavourably  situated,  becomes  changed  in  such 
a  manner  as  to  present  one  of  the  extremities  (espe- 
cially the  pelvic)  of  the  ellipse,  that  it  can  enter  and 
pass  through  the  pelvis,  aided  by  the  powers  of  the 
mother  alone. 

How  do  you  explain  the  law 
by  which  this  change  is  ef- 
fected ?  As  already  mentioned, 
it  depends  probably  upon  the 
flexibility  of  the  fetus,  and 
upon  the  direction  of  the  ute- 
rine forces  aided  by  the  con- 
tractions of  the  abdominal 
muscles. 

What  is  the  probable  pro- 
portion of  cases  of  spontane- 
ous version,  in  shoulder  pre- 
sentations ?  It  has  been 
rated  at  one  case  of  sponta- 
neous version,  to  one  thousand 
cases  of  shoulder  presenta- 
tions. 

ALWAYS  RECTIFY  DEVIATED  PRESENTATIONS  IF 
POSSIBLE. 

Should  you  ever  wait  for  spontaneous  version,  in 
any  cases  of  shoulder  presentations,  or  of  those  of  the 
lower  or  upper  part  of  the  body  ?  It  would  not  be 
proper  to  wait,  if  it  be  possible  to  act  judiciously  for 
correcting  the  deviation. 

Suppose  you  find  the  lower  part  of  the  body  pre- 
sent ;  what  is  the  rule  of  practice  ?  To  pass  in  the 
hand,  and  bring  down  the  breech  or  feet. 


214 


MEDICINE   AND   SURGERY 


Suppose  some  portion  of  the  upper  part  of  the  body 
present,  what  should  you  do  ?  Pass  in  the  hand,  and 
make  version  by  the  feet. 

What  should  be  the  condition  of  the  soft  parts,  be- 
fore you  proceed  to  an  attempt  at  version?  They 
should  be  relaxed  or  dilated,  to  an  extent  sufficient  to 
avoid  contusion  or  laceration. 

When  you  have  diagnosticated  such  a  deviation, 
should  you  endeavor  to  preserve  the  membranes  till  all 
the  parts  are  dilated  ?  This  is  proper  in  all  cases 
of  real,  or  supposed  deviation,  until  the  parts  are  well 
dilated. 

RULE  FOR  THE  USE   OF  THE  HAND. 

What  is  the  rule  for  the  use  of  the  particular  hand, 
and  its  mode  #  introduction  ?  1.  That  rule  which 
applies  to  version  by  the  knees  or  feet,  in  all  cases, 
viz. :  the  hand,  the  palm  of  which,  looks  towards 
the  abdomen  of  the  child,  except  in  dorso-sacral  posi- 


Fig.  87. 


tion  of  the  shoulders.  2.  When  it  is  ascertained  that 
the  dorsum  of  the  child  is  towards  the  pubes  of  the 
mother,  the  hand  is  to  be  introduced,  which   can  be 


OF  THE   LYING-IN   CHAMBER.  215 

readily  flexed  into  the  iliac  fossa  in  which  the  breech 
is  situated ;  this  will  be  the  right  hand  for  the  breech 
in  the  right  iliac  fossa,  and  the  left  hand  in  the  left 
iliac  fossa. 

In  either  of  these  cases,  the  hand  is  to  be  carried  up 
supine  beyond  the  child  or  between  it  and  the  sacrum 
along  one  of  its  sides  to  the  breech,  then  along  the 
thighs  to  the  knees  or  feet,  which  of  course  are  to  be 
brought  down,  by  the  left  hand  in  the  second,  and  by 
the  right  hand,  in  the  first  position  of  the  feet  or  knees. 

Will  the  same  rule  apply  to  the  case  of  dorso-sacral 
positions  ?  No :  here  the  reverse  obtains,  that  is, 
in  the  dorso-sacral  position  of  the  right  shoulder,  in 
which  the  breech  is  in  the  left  iliac  fossa,  the  right 
hand  must  be  passed  up  in  front  of  the  child  and  in  a 
semi-prone  condition  :  while  in  the  dorso-sacral  posi- 
tion of  the  left  side  in  Avhich  the  breech  is  in  the  right 
iliac  fossa  the  left  hand  must  be  passed  up  in  a  semi- 
prone  condition  between  the  child  and  the  lateral 
part  of  the  uterus. 

Fig.  88. 


In  passing  the  hand  for  the  purpose  of  reaching 
the  hams  or  feet  for  version,  is  it  proper  to  persist  in 


216  MEDICINE   AND   SURGERY 

carrying  it  up  where  there  is  a  uterine  contraction  ? 
All  attempts  at  acting  with  the  hand  in  the  uterus, 
must  be  suspended  as  soon  as  the  contraction  takes 
place,  and  moreover,  the  hand  must  be  expanded  upon 
the  part  of  the  child  with  which  it  is  in  contact  at 
that  time,  lest  the  knuckles  should  cause  rupture  of 
the  uterus  or  other  injury. 

Is  it  sometimes  necessary  to  rotate  the  body  of  the 
child  on  its  own  axis,  in  some  of  the  shoulder  presen- 
tations for  the  purpose  of  getting  down  the  feet  ?  This 
is  unavoidable,  particularly  in  dorso-sacral  positions 
of  either  side. 

Suppose  the  body  has  been  under  pressure  of  the 
uterus,  and  the  shoulder  is  wedged  down  in  the  pelvis, 
must  you  act  at  once,  or  endeavor  to  allay  the  con- 
tractions of  the  uterus  ?  It  is  a  fundamental  rule, 
never,  if  possible  to  avoid  it,  to  act,  in  attempting  at 
least  the  first  steps  of  version,  unless  when  the  uterus 
is  in  a  state  of  relaxation.  If  therefore  the  tonic 
contraction  of  the  uterus  upon  the  child,  be  such  that 
it  is  immoveable  in  the  uterus,  efforts  must  be  made 
by  bleeding,  warm  bath,  nauseants  or  opiates,  to  over- 
come the  constriction  which  this  powerful  organ  exerts 
upon  its  contents. 

INSTRUMENTAL  DELIVERY  IN  SHOULDER  PRESEN- 
TATIONS. 

Suppose  the  child  be  dead,  or  you  have  reason  to 
believe  that  the  mother  will  die  if  not  speedily  de- 
livered, what  would  you  do  ?  Deliver  by  the  crotchet 
or  other  appropriate  instrument. 

How  would  you  proceed  to  do  this  ?  Eviscerate  the 
.thorax  by  perforating  it,  and  removing  its  contents; 
then  remove  portion  after  portion  of  the  child,  as  it 
comes  within  reach. 

Should  you  always  favor  the  process  of  version  by 
the  feet,  even  after  eviscerating  the  child,  rather  than 
to  force  the  head  down  first  ?  This  is  preferred  by 
good  authority. 


OF   THE    LYING-IN    CHAMEER.  217 

Suppose  a  hand  should  descend  with  the  head,  what 
practice  should  you  resort  to  ?  Support  it  at  the  su- 
perior strait  while  the  head  descends. 

Should  you  ever  make  traction  effort  upon  the  arm 
in  case  of  its  descending  first  under  any  circumstances  ? 
Never ;  such  a  practice  would  always  complicate  the 
difficulty  of  subsequent  delivery. 

FURTHER  INQUIRIES  ON  THE  DIAGNOSIS,  AND  MODE  OF 
ACTION  IN  CASES  OF  FALSE  PAINS  AND  THE  DEVI- 
ATED POSITION  OF  THE  CEPHALIC  OR  PELVIC  POLE 
OF  THE  FETUS. 

What  condition  of  the  os  uteri  should  be  found  in 
regular  labor  ?  It  should  usually  be  found  somewhat 
dilated ;  and  when  a  finger  is  applied  to  it  during  a 
pain  depending  upon  uterine  contraction,  it  will  be 
found  to  be  tightened  up  by  being  drawn  as  it  were, 
over  the  lower  segment  of  the  ovum. 

Is  it  always  easy  to  determine  whether  the  patient 
is  in  labor  or  not  ?  To  the  young  practitioner  it  is 
often  very  difficult ;  even  experienced  accoucheurs 
cannot  always  decide  positivel}^. 

What  are  the  usual  means  of  discriminating  true  from 
false  pains  by  the  history  of  the  case  ?  By  the  character 
of  the  pains :  true  labor  pains  are  mostly  alternate,  show- 
ing a  distinct  interval  of  ease  between  them,  while  in 
colic,  or  neuralgic  pains,  they  are  more  irregular,  and  in 
the  pains  attendant  upon  inflammation,  they  are  more 
constant  and  accompanied  by  more  febrile  action. 

Suppose  you  had  reason  to  conclude  that  the  pa- 
tient was  afflicted  with  false  pains,  how  should  you 
attempt  to  relieve  them  ?  By  recourse  to  efforts  to 
remove  the  supposed  causes ;  if  they  depended  upon 
constipation,  by  cathartics,  or  enemata ;  if  upon  in- 
flammatory action,  by  bleeding,  &c. ;  if  upon  neu- 
ralgia or  spasms,  by  proper  anodynes,  or  counter  irri- 
tants, &c. 

Can  you  always  positively  assure  a  woman  that  she 
is  in  labor,  if  you  find  her  os  uteri  dilated  to  the  size 
of  a  ten  cent  piece  ?  Though  this  circumstance,  ac- 
19 


218  MEDICINE    AND    SURGEHY 

companled  by  pains  of  a  more  or  less  regular  cliarac- 
ter,  may  be  considered  as  sufficient  data  for  diagnos- 
ticating the  actual  existence  of  labor,  yet  it-  has  hap- 
pened to  some  practitioners  to  observe  this  state  of 
things  in  women  who  have  subsequelitly  gone  from 
one  to  four  weeks  after  this,  before  they  were  delivered. 

CHANGES  OF  POSITION  OF  FETUS   IN  THE    EARLY  PART 
OF  LABOR. 

Is  any  change  effected  in  the  position  of  the  child 
during  the  early  stage  of  labor?  Great  changes  are 
sometimes  effected  in  deviated  positions,  even  before 
the  OS  uteri  is  well  dilated,  or  the  child  driven  down 
into  the  lower  pelvis. 

How  are  we  to  account  for  such  changes  ?  First,  in 
the  peculiar  form  of  the  abdominal  and  super-pelvic 
cavity ;  and  secondly,  in  the  flexibility  of  the  child, 
its  form  is  adapted  to  the  shape  of  the  uterus,  in  such 
manner  as  to  make  its  long  diameter  correspond  to 
that  of  the  long  diameter  of  the  uterus,  whatever  this 
may  be. 

Some  persons  have  compared  the  fetus  in  utero,  to 
a  cork  inside  of  a  bottle,  which  can  pass  through  the 
neck  only  in  a  certain  direction,  is  this  comparison 
correct  ?  Not  exactly  so,  as  the  child  is  more  pliable, 
yet  it  must  finally  escape  only  in  the  direction  of  its 
long  diameter. 

When  deviations  of  presentations  of  the  body  occur, 
is  it  proper  for  you  to  wait  until  spontaneous  version 
takes  place  ?  It  would  not  be  best :  we  should  always 
endeavor,  if  under  favorable  circumstances,  to  intro- 
duce the  hand,  and  deliver  by  the  feet, 

PRESENTATION  OF  THE  SIDES  OF  THE  HEAD. 
Are  you  liable  to  meet  with  presentations  of  the  side 
of  the  child's  head  ?  They  may  occur  when  there  is 
great  obliquity  of  the  uterus,  or  the  top  of-  the  head 
should  be  arrested  in  a  certain  direction  at  one  side 
of  the  superior  strait. 


OF   THE   LYING-IN    CHAMBER.  219 

How  are  you  to  recognize  them  ?  By  the  pre- 
sence of  an  ear  and  a  portion  of  the  coronal,  or  of 
the  lambdoid  suture,  a  mastoid,  or  a  zygomatic  pro- 
cess, &c. 

How  are  you  to  correct  this  kind  of  deviation  ?  If 
possible,  push  up  the  head  of  the  child  by  the  hand, 
and  bring  it  to  its  proper  relations  with  the  pelvis. 

OTHER  DEVIATIONS. 

When  the  nape  of  the  neck  presents  to  the  centre 
of  the  pelvis,  what  is  the  indication  ?  To  correct  the 
deviation  according  to  the  general  rules  already  pro- 
posed. 

May  it  happen  in  practice  that  various  parts  of  the 
body,  as  the  hip,  the  back,  one  side,  &c.,  may  present 
to  the  centre  of  the  pelvis  ?  However  rare,  they  are 
stated  to  have  occurred. 

How  do  these  generally  result  in  practice  ?  Mostly 
in  the  presentation  of  a  shoulder,  or  hip,  or  of  the 
breech  or  feet,  &c. 

Should  you  be  much  disturbed  by  the  occurrence 
of  the  third  position  of  the  breech  ?  Inasmuch  as  we 
can  have  considerable  command  over  the  rotation  of 
the  child's  shoulders  by  proper  manipulations  upon 
the  breech,  we  should  apprehend  little  inconvenience 
from  this  position. 

Should  you  interfere  with  it  before  the  breech  has 
descended  into  the  cavity  of  the  mother's  pelvis? 
No ;  it  is  quite  unnecessary  to  interfere  at  all  until 
the  breech  has  fairly  entered  the  cavity  of  the 
pelvis. 

What  should  you  then  do  ?  Assist  or  compel  rota- 
tion on  to  one  of  the  anterior  planes  to  convert  it  into 
the  first  position. 

Is  it  probable  that  the  direction  of  the  head  is  mo- 
dified by  the  rotation  of  the  shoulders  as  it  descends 
into  the  strait  ?  This  idea  is  entertained  by  some 
who  believe  that  in  rotations  of  the  head  in  cephalic 


220  MEDICINE    AND    SURGERY 

presentations  the  shoulders  are  not  modified  by  such 
rotation. 

What  is  the  mechanism  of  breech  presentations  in 
the  posterior  positions  ?  The  contractions  of  the  ute- 
rus impel  the  right  hip,  (if  we  take  the  fourth  posi- 
tion as  the  type  of  these  posterior  varieties,)  along 
the  right  anterior  inclined  plane  towards  the  arch  of 
the  pubes,  while  the  left  hip  is  driven  along  the  left 
posterior  inclined  plane  to  the  middle  line  of  the  sa- 
crum to  become  the  sacral  hip  and  usually  to  be  de- 
livered first.  The  body  is  then  carried  down  in  a  state 
of  lateral  flexion,  until  the  right  shoulder  is  carried 
down  on  the  right  anterior,  and  the  left  on  the  left 
posterior  inclined  plane,  to  be  delivered  at  the  vulva. 
There  is  then  a  disposition  for  restitution  to  the  ob- 
lique position  which  the  head  occupies ;  that  is,  with 
the  spine  towards  the  posterior  part  of  the  right 
thigh,  and  the  umbilicus  towards  the  anterior  portion 
of  the  left  thigh  ;  but  the  occurrence,  or  non-occur- 
rence of  this  will  depend  upon  the  manner  in  which 
the  body  is  supported  on  the  hand  of  the  accoucheur, 
or  on  the  bed  of  the  mother.  As  the  fetus  is  now 
chiefly  or  entirely  beyond  the  reach  of  uterine  action, 
the  voluntary  powers  of  the  mother  mainly  drive  down 
the  head  of  the  child  with  its  occiput  on  the  right  pos- 
terior inclined  plane  to  pass  on  the  perinseum,  while 
the  chin,  mouth,  nose,  eyes,  forehead,  and  bregma 
successively  escape  under  the  arch  of  the  pubes. 

Is  it  safe  for  you  to  attempt  rotation  in  a  direction 
opposite  to  that  which  it  would  spontaneously  take, 
and  thus  convert  it  into  an  anterior  position  ?  Some 
practical  accoucheurs  think  it  safe  and  easy  after  the 
shoulders  are  delivered. 

At  what  part  of  the  pelvis  can  this  forced  rotation 
be  efl'ected  ?  While  in  the  cavity  and  not  in  either 
of  the  straits  of  the  pelvis. 

What  should  you  do  with  a  sixth  position  of  the 
pelvis  ?  Endeavor  first  to  convert  it  into  a  fourth 
or  fifth,  and  when    the  shoulders   are    delivered,    by 


OF   THE   LYING-IN   CHAMBER.  221 

the  aid  of  the  finger  convert  the  head  into  a  first  or 
second  position. 

Why  can  we  do  this  with  greater  safety  than  in 
cases  of  original  cephalic  presentations  ?  Because  we 
are  in  these  cases  able  to  modify  the  direction  of  the 
body  to  that  in  which  we  force  the  head. 

DEVIATED  BREECH  PRESENTATIONS. 

Are  breech  presentations  liable  to  any  deviations 
of  position  ?  They  are  :  hence  we  may  have  presen- 
tations of  the  loins,  or  either  one  of  the  ilia,  &c. 

Do  deviations  of  the  breech  usually  become  recti- 
fied spontaneously  ?     Usually  they  do. 

Suppose,  however,  there  should  be  great  delay  in 
the"  descent  of  the  breech,  should  any  attempts  be 
made  to  rectify  them  ?  It  would  be  proper  to  facili- 
tate the  delivery,  by  rectifying  the  position. 

HOW   TO  RECTIFY  THEM. 

What  is  the  rule,  in  reference  to  the  use  of  the 
hand  in  these  deviated  positions  of  the  breech  ?  Pass 
up  that  hand  the  palm  of  which  will  look  towards  the 
abdomen  of  the  child. 

BRINGING  DOWN  THE  FEET   IN   BREECH  TRESEN- 
TATIONS. 

Can  you  ever  bring  down  the  feet  to  any  advan- 
tage? The  advantages  of  this  manipulation  would 
rarely  be  commensurate  with  the  risk  of  attempting 
it,  unless  the  breech  is  high  up  and  the  child  easily 
moveable  in  the  uterus. 

Suppose  it  becomes  necessary  to  bring  down  the 
feet  in  original  breech  presentations,  how  would  you 
proceed  to  do  it  ?  The  soft  parts  being  sufiiciently 
dilated,  introduce  the  proper  hand,  push  up  the  breech 
if  necessary,  then  pass  it  along  the  thighs  to  the 
knees,  to  descend  upon  the  legs  and  seize  the  feet. 

W^hich  hand  should  you  use  ?  That,  the  palm  of 
w^hich  looks  to  the  abdomen,  or  the  back  part  of  the 
thighs  of  the  child. 

19* 


222  MEDICINE   AND    SURGERY 

Do  jou  bring  down  the  feet  in  the  same  position 
at  which  the  breech  was  situated  ?  This  would  always 
be  right,  as  forced  rotation  can  in  such  cases,  if  ne- 
cessary, be  effected  by  acting  upon  the  legs,  when 
they  are  brought  down. 

Suppose  the  labor  be  far  advanced,  and  the  breech 
becomes  arrested  in  the  cavity  of  the  pelvis,  or  infe- 
rior strait,  what  then  would  you  do  ?  Attempt  to 
bring  down  the  breech  by  passing  up  the  hand  and 
fixing  a  thumb  in  one  groin  and  a  finger  in  the  other. 

FILLET. 

Suppose  there  was  not  a  space  sufficient  for  the 
passage  of  the  hand  and  breech  together,  what  in- 
strumental means  have  you?  The  fillet,  which  if 
it  can  be  applied,  would  be  well  adapted  for  this 
purpose. 

What  is  the  fillet  ?  A  thin  strong  silk  ribbon,  or 
a  thin  linen  tape  of  such  width  as  to  admit  its  being 
passed  along  a  fold  in  the  ham  or  groin. 

How  is  this  to  be  efi*ected,  while  this  fold  is  still 
within  the  pelvis  ?  This  instrument  properly  lubri- 
cated, is  to  have  one  of  its  extremities  doubled  up  in 
numerous  plaits  or  folds,  which  are  to  be  carried  upon 
the  point  of  the,  index  finger  of  the  proper  hand  and 
applied  to  the  fold  in  the  groin  or  ham  ;  the  fillet  is 
then  to  be  passed  on  the  point  of  the  finger  till  it  is 
found  on  the  opposite  side  of  the  limb  ;  the  plaits  are 
then  to  be  drawn  out  at  the  vulva,  and  thus  the  fold 
of  the  groin  or  ham,  will  be  secured  in  it.  With  this 
tape  or  ribbon,  a  very  considerable  degree  of  force  can 
be  exerted  and  very  efficient  aid  often  rendered. 

What  resources  have  you  for  the  application  of  the 
fillet,  if  the  fold  of  the  ham  or  groin  is  beyond  the 
reach  of  the  finger  ?  A  slightly  curved  silver  canula, 
containing  a  watch-spring,  with  an  eyelet  mounted  upon 
it ;  this  eyelet  having  a  small  loop  of  strong  thread 
in  it  is  to  be  carried  up  to  the  fold  in  the  ham  or 
groin,  upon  the  end  of  the  canula,  it   is  then  thrust 


OF   THE    LYING-IN    CHAMBER.  223 

forward  along  the  fold  to  appear  at  the  opposite  side 
of  the  limb,  the  end  of  the  fillet  is  to  be  passed 
through  this  loop,  the  steel-spring  stillet  is  then  to 
be  retracted,  and  the  fillet  thus  drawn  over  the  groin 
or  ham,  and  its  extremity  brought  within  reach  of 
the  hand  of  the  accoucheur,  who  is  thus  enabled  to 
act  with  it. 

BLUNT  HOOK. 

What  other  instrument  have  we  for  the  delivery  of 
the  hips  ?     The  blunt  hook. 

Fig.  89. 


r= 


Where  are  you  to  fix  it  ?  In  the  groin  if  you  need 
to  aid  descent  of  the  breech,  or  in  the  ham  if  you 
have  to  use  instrumental  assistance,  in  cases  of  pre- 
sentation of  the  knees. 

How  is  it  to  be  prepared  for  use  ?  Properly  warmed 
and  lubricated. 

Is  it  proper  to  apprise  the  patiei^  or  her  friends, 
of  the  necessity  of  its  use  ?  With  few  if  any  ex- 
ceptions, the  necessity  for  all  such  instruments  should 
be  explicitly  stated,  and  consent  obtained. 

Does  the  introduction  and  use  of  this  instrument 
give  pain  to  the  mother  ?  None,  if  properly  man- 
aged. 

Into  which  groin  or  ham,  is  it  to  be  passed  ?  Into 
the  sacral  groin  or  ham  if  possible,  though  it  is  usu- 
ally most  convenient  and  even  better  to  fix  it  in  the 
pubal  limb,  while  in  the  upper  part  of  the  pelvis. 

How  are  you  to  guide  the  instrument  to  its  point 
of  application?  Upon  the  end  of  one  or  more  fin- 
gers, to  the  body  or  thigh  of  the  child,  and  when 
passed  sufficiently   far  onward   the   end  of  the   hook 


224 


MEDICINE    AND    SURGERY 


should  be  made  to  slide  around  on  one  of  these  parts 
to  the  fold  into  which  it  is  to  be  fixed. 


Fig.  90. 


To  whom  is  due  the  credit  of  having,  placed  a 
guard  upon  the  blunt  hook,  to  render  traction  with 
it  less  hazardous  to  the  groin  or  ham  of  the  child 
when  either  is  too  large  to  allow  the  end  of  the  hook 
to  pass  securely  behind  it,  or  to  protect  the  mother 
from  injury  when  the  groin  or  ham  has  to  be  seized 
so  high  up  that  the  point  cannot  be  easily  reached  by 
the  finger?  Dr.  John  Livingston  Ludlow,  of  Phila- 
delphia. 

How  is  this  guard  to  be  applied  ?  First  put  the 
hook  on  the  part  on  which  the  traction  force  is  to  be 
exerted,  then  carry  the  point  of  the  guard  to  that  of 
the  hook,  when   if  the   notch  will  w^ell   adapt  itself  to 


OF   THE    LYING-IN    CHAMBER.  225 

the  pivot  on  the  shaft  of  the  hook,  it  will  form  a  loop, 
less  injurious,  and  more  reliable  than  that  of  a  fillet. 


Can  jou  use  the  blunt  hook  to  any  advantage  in 
cases  in  which  it  is  difficult  to  bring  down  the  arms 
of  the  child  with  the  fingers  ?  Its  use  is  sometimes 
indispensable,  when  the  finger  of  thei  accoucheur  fails 
to  accomplish  the  object. 

In  what  particular  case,  can  the  blunt  hook  be  re- 
sorted to,  for  the  delivery  of  the  head,  in  breech  pre- 
sentations ?  When  it  is  impossible  to  produce  flexion 
by  the  hand  or  vectis. 

How  are  you  to  use  it,  and  where  are  you  to  fix 
it  ?  First,  try  it  in  the  mouth  carefully,  next,  it  may 
be  fixed  upon  the  lower  edge  of  the  orbit. 

PROLArSE  OF  THE  UMBILICAL  CORD. 

Does  the  descent  of  the  umbilical*  cord  ever  com- 
plicate labor  ?  It  does  very  materially,  so  far  as  the 
life  of  the  child  is  concerned,  unless  the  labor  is  very 
rapid  and  speedily  terminates. 

How  does  it  do  this  ?  By  the  risk  of  pressure 
upon  the  cord,  and  arresting  the  circulation  through 
it,  and  speedily  destroying  the  child  by  suspending 
the  process  of  hematosis. 

What  is  the  indication  in  prolapsus  of  the  umbi- 
lical cord  ?  To  carry  it  above  the  superior  strait, 
and  let  the  head  descend  first. 

How  are  we  to  retain  it  there  ?  Some  attach  it 
to  loops  at  the  ends  of  flexible  catheters,  but  the  bet- 
ter plan  is  to  carry  it  up  in  a  pocket,  on  a  piece  of 
whale  bone,  above  the  superior  strait,  and   retain  it 


226  MEDICINE   AND    SURGERY 

till  the  head  fairly  engages,  then  withdraw  the  whale 
bone  and  leave  the  cord  and  the  pocket  to  be  deli- 
vered after  the  child. 

Should  you  expect  to  gain  any  benefit  by  bringing 
down  the  feet,  in  such  cases  ?  We  think  this  rarely, 
if  ever  advisable,  as  the  cord  would  still  be  in  dan- 
ger. If  reduction  of  the  cord  be  impracticable,  we 
would  employ  the  forceps  if  the  head  were  within 
reach. 

TOO  SHORT  A  CORD. 

Can  a  very  short  cord  complicate  the  labor  very  se- 
riously ?  It  may  slightly  retard  delivery  in  some 
cases,  but  the  chief  inconvenience  it  produces  is  from 
the  sudden  dragging  out  of  the  placenta,  and  some- 
times also  the  uterus  with  it,  and  causing  inversion 
of  that  organ. 

TOO    LARGE    A    HExVD    FROM    HYDROCEPHALUS  OR  ANY 
OTHER  CAUSE. 

Do  preternatural  enlargements  of  the  child  or  of 
its  head,  ever  complicate  the  labor  ?  Enlargements 
of  this  kind  may  not  only  complicate  the  labor,  but 
render  it  impracticable  without  the  aid  of  proper  in- 
struments. 

What  practice  is  indicated  under  such  circum- 
stances ?  Tap  the  child's  head,  evacuate  the  water, 
or  open  the  head  and  evacuate  the  brain ;  complete 
the  delivery  by  the  forceps  or  the  crotchet,  if  either 
be  necessary. 

Does  the  base  of  the  cranium  ever  offer  any  special 
obstacle  to  delivery?  Rarely,  if  ever,  provided  it  be 
brought  down  in  the  proper  direction. 

In  what  direction  is  the  base  of  the  cranium  to 
be  brought  down,  after  the  vault  has  been  removed? 
Always,  if  possible,  with  its  facial  extremity  fore- 
most. In  cases  in  which  the  pelvis  is  of  normal  size 
and  this  direction  is  easily  followed,  such  change  in 
the  position  of  the  face  is  less  necessary,  as  in  many, 


OF    THE    LYING-IN    CHAMBER.  227 

peihaps  in  most,  such  instances,  the  head  can  pass 
in  almost  any  direction  after  the  vault  of  the  crani- 
um has  coHapsed,  after  the  escape  of  the  brain,  or 
even  the  serum  from  a  hydrocephalic  enlargement. 

DOUBLETS  OR  TRIPLETS. 

Do  you  consider  labor  with  twins,  as  more  hazard- 
ous to  the  mother  than  single  pregnancies?  Not 
often  so. 

Fig.  92. 


Are  evidences  of  two  or  more  fetuses  in  utero  con- 
spicuous, usually?  There  are  few,  if  any  rational 
signs  to  be  depended  upon  as  evidences  of  compound, 
or  twin,  or  triplet  pregnancy. 

What  is  the  most  certain  means  of  diagnosis  of 
compound  pregnancies  ?     Auscultation. 

What  must  you  hear  to  convince  you  of  the  ex- 
istence of  twins  or  triplets  ?  The  sound  of  two  or 
more  hearts,  each  at  different  parts  of  the  uterus. 

What  are  the  principal  causes  which  render  twin 
or  triplet  cases  of  labor  more    tedious  ?     The  great 


228  METCDINE    AND    SURGERY 

distension  of  the  uterus,  and  the  unfavorable  direc- 
tion in  which  the  contractions  fall  upon  either  of 
the  fetuses. 

Is  the  second  stage  rapid  ?  It  is  usually  so,  when 
once  one  fetus  is  fairly  engaged,  because  it  is  usually 
really  smaller  than  when  it  is  simple  pregnancy. 

Is  there  any  more  danger  in  the  third  stage  of 
labor  in  compound,  than  in  simple  pregnancies  ?  In 
consequence  of  the.  great  distension  of  the  uterus 
during  the  latter  periods  of  pregnancy  in  such  cases, 
it  is  more  liable  to  acquire  an  atonic  state,  and  hence 
the  greater  risk  of  hemorrhage,  &c. 

Are  labors  in  twin  cases,  liable  to  become  compli- 
cated by  the  descent  of  any  portion  of  the  other  child 
when  one  has  originally  presented  ?  This  accident 
has  been  known  to  occur,  and  it  is  easy  to  suppose 
that  this  complication  is  often  liable  to  happen. 

Suppose  the  head  of  one  child,  and  the  feet  of  the 
other  should  engage  in  the  pelvis  at  the  same  time, 
how  should  you  manage  the  case  ?  If  possible,  push 
up  the  feet,  and  let  the  head  descend ;  but  if  not, 
apply  the  forceps  with  a  view  to  deliver  the  head  by 
the  side  of  the  feet ;  if  this  expedient  should  fail, 
it  has  been  advised  to  resort  to  craniotomy,  and  em- 
bryulcia. 

What  other  complications  may  take  place  ?  A 
great  variety ;  one  of  the  most  difficult  and  interest- 
ing, perhaps,  is  that  in  which  as  one  descends,  with 
the  pelvic  extremity  first,  its  chin  becomes  locked  un- 
der the  chin  of  the  other,  which  was  presenting  the 
cephalic  extremity,  and  which  had  gotten  down  into 
the  cavity  of  the  pelvis. 

How  should  you  proceed  with  a  view  to  save  the 
life  of  one  child  ?  Eviscerate  the  child  which  has 
descended,  detruncate  it,  leave  the  head  in  the  cavity 
of  the  uterus,  push  it  up  above  the  superior  strait ; 
then  deliver  the  second  child,  and  afterwards  remove 
the  head  of  the  first. 


OF   THE    LYING-IN    OIIAMBER.  229 

OBLIQUITIES  OF  THE  UTERUS. 

Do  any  complications  of  labor  occur  from  obliqui- 
ties of  the  uterus?  It  is  believed  that  many  cases 
of  complication  or  deviation,  depend  upon  obliqui- 
ties of  the  uterus,  by  which  its  axis  is  thrown  out  of 
a  line  with  that  of  the  pelvis. 

In  what  direction  do  these  obliquities  usually  occur  ? 
Laterally  and  anteriorly* 

Do  obliquities  of  the  uterus  usually  correct  them- 
selves ?  They  mostly  do  by  the  aid  of  the  contrac- 
tions of  the  abdominal  muscles ;  not  always  how- 
ever, until  after  they  have  caused  serious  deviation 
in  the  direction  of  the  presentation  of  the  fetus. 

How  should  you  correct  those  deviations  which 
interfere  with  ready  delivery  ?  Generally  by  placing 
the  patient  on  the  part  of  her  body  opposite  to  that 
to  which  the  uterus  is  inclined. 

Are  you  justifiable  in  making  any  attempt  at  cor- 
rection within  the  pelvis  ?  This  may  sometimes  be 
done  advantageously  by  acting  on  the  orifice  of  the 
uterus  steadily,  but  moderately  in  the  absence  of  a 
pain,  and  retaining  it  in  the  acquired  position  during 
the  next  pain,  &c. 

SOMETIMES  DIFFICULT  TO  FIND  THE  OS  UTERI. 

Are  there  any  cases  in  which  the  os  uteri  cannot 
be  reached  by  the  finger  at  the  commencement  of 
labor  ?  Cases  of  this  kind  have  been  met  with,  and 
the  ignorant  accoucheur  has  been  persuaded  that  there 
was  no  OS  uteri  at  all,  and  from  the  apparent  neces- 
sity of  the  case,  has  proceeded  to  make  one  with  his 
bistoury. 

How  is  this  occurrence  to  be  explained  ?  Either 
by  the  very  considerable  anterior  obliquity  of  the 
uterus,  or  by  the  very  great  development  of  the  an- 
terior portion  of  the  neck  of  the  uterus,  or  both  of 
these  together. 

By  what  plan  of  practice  is  it  to  be  corrected  ?  Bv 
20 


230 


MEDICINE   AND    SURGERY 


passing  a  bandage  around  the  abdomen  of  the  patient, 
and  thus  compressing  the  fundus  and  body  of  the 
uterus  backward  ;  then  wait  until  the  first  stage  pf 
labor  is  nearly  completed,  by  which  time  you  can  reach 
the  anterior  lip,  which  you  can  draw  gently  forward. 

CAUSES  ARRESTING  THE  HEAD  ABOVE  THE  SUPERIOR 
STRAIT. 

How  are  you  to  account  for  the  occurrence  of  cases 
in  which  the  head  of  the  child,  instead  of  engaging  in 
the  centre  of  the  pelvis,  becomes  arrested  upon  the  top 
of  the  pubes  ?  They  most  probably  depend  upon 
great  relaxation  of  the  muscles  at  the  lower  part  of 
the  abdomen,  impacted  feces,  or  pelvic  tumors. 

How  are  you  to  manage  cases  of  this  kind  ?  Make 
pressure  upon  the  hypogastric,  or  rather  upon  the 
pubic  region.  If  the  case  offered  any  unusual  diffi- 
culty, we  would  propose  the  application  of  a  firm 
bandage  around  tlie  pelvis,  and  then  urge  the  patient 
to  take  several  successive  pains  in  a  sitting  or  stand- 
ing position  strongly  inclined  forwards.  In  all  cases 
of  impaction  of  feces  the  rectum  must  be  cleared  by  in- 
jections or  instruments. 

LABOR  COMPLICATED  WITH  PROLAPSION  OF  THE 
BLADDER,  VAGINA,  &C. 

92.  Do   not    prolapsions   of  the 

bladder,  or  of  the  vagina  or  the 
bowels,  sometimes  complicate 
labor  ?  The  progress  of  labor 
may  be  much  retarded  by  a 
vaginal  vesicle  as  shown  in 
fig.  92,  by  prolapsion  of  the 
vagina  as  well  as  in  some  cases 
by  the  spreading  out  of  the  an- 
terior lip  of  the  uterus  itself 
over  the  head  of  the  child,  and 
between  it  and  the  pubcs. 

How   is    the   difficulty  aris- 
ing     from     either    of     these 


Fig. 


OF   THE    LYING-IN    CHAMBER.  231 

causes  to  be  overcome  ?  If  it  arise  from  a  prolapsed 
bladder,  the  urine  should  be  drawn  from  it  bj  a  ca- 
theter if  possible — afterwards  it,  or  the  vagina,  or  the 
lip  of  the  uterus  must  be  carried  upon  the  tip  of 
one  or  more  fingers  above  the  top  of  the  pubes,  and 
there  retained  till  a  pain  forces  the  presenting  part  of 
the  child  below  it. 

DR.  B'S.  CASE  OF  HERNIA  OF  THE  INTESTINES  INTO  THE 
PERITONiEL  CUL-DE-SAC. 

What  is  Dr.  Meig's  description  and  treatment  in 
his  excellent  work  on  obstetrics,  of  a  case  of  labor 
complicated  by  a  prolapsion  or  hernia  of  the  bowels? 
Mrs.  R.  was  in  violent  labor,  which  had  continued  long, 
but  without  any  effect.  Dr.  B.  requested  me  to  visit 
her  with  him.  The  vagina  was  pressed  forwards  to- 
wards the  symphysis  pubes,  by  a  tumor  behind  it, 
filling  up  the  excavation  of  the  pelvis  and  preventing 
the  descent  of  the  head.  I  learned  by  examination 
that  this  tumor  consisted  of  a  great  mass  of  intestinal 
convolutions  that  had  fallen  down  below  the  strait 
and  that  was  kept  there  by  the  violent  tenesmus,  as 
well  as  by  the  gravid  womb  above  it.  Indeed  the 
mass  was  to  a  certain  extent,  incarcerated  within  the 
excavation  of  the  pelvis.  The  efforts  of  the  patient 
to  bear  down  upon  her  pains  were  most  violent,  and 
the  distress  accompanying  them  apparently  intense. 
I  introduced  my  fingers  into  the  lower  part  of  the  va- 
gina, and  thrusting  the  posteri'or  wall  of  that  tube 
backwards,  got  the  points  of  the  fingers  beneath  the 
tumor,  which  occupied  the  recto-vaginal  cul-de-sac  of 
the  peritonaeum.  A  little  patient  manipulation 
caused  portions  of  the  gut  to  ascend  into  the  abdo- 
men, and  in  a  short  time  the  whole  mass  fled  upwards 
above  the  brim,  whereupon  the  expulsive  efforts  of 
the  womb  being  no  longer  opposed  by  it,  the  child  was 
speedily  and  safely  born. 


232  MEDICINE    AND    SURGERY 


LABOR    COMPLICATED    BY    LESIONS    OF     FUNCTION    OF 
THE  NERVOUS,  VASCULAR,  OR   MUSCULAR    SYSTEM. 

Are  there  any  abnormal  conditions  of  the  patient 
which  may  interfere  with  the  function  of  parturition  ? 
There  are  many  depending  upon  conditions  of  the 
nervous,  vascular,  and  muscular  systems. 

RIGIDITY. 

What  is  the  most  common  of  these  abnormal  con- 
ditions ?  Rigidity  of  the  os  uteri,  or  perinneum,  from 
original  tonicity,  depending  perhaps  upon  plethora, 
and  again  in  some  instances  the  rigidity  may  be 
caused  by  an  alteration  of  structure,  as  adhesions, 
cicatrices,  &c. 

What  process  most  readily  overcomes  the  rigidity  ? 
Increased  secretion,  promoted  by  bleeding,  warm  bath- 
ing, fomentations,  &c. 

Does  rigidity  ever  depend  upon  irritation,  the  cause 
of  which  is  direct  or  remote  ?  It  may,  and  no  doubt 
does. 

May  the  hand  of  the  accoucheur  ever  be  the  cause 
of  this  rigidity?  By  too  frequent,  or  too  roughly 
touching  the  orifice  of  the  uterus,  it  may  become  irri- 
tated, rigid,  and  even  inflamed. 

May  too  early  a  rupture  of  the  membranes  give  rise 
to  rigidity  ?  It  is  probable  that  in  some  cases  the  too 
early  drainage  of  the  waters,  and  the  pressure  of  the 
presenting  part  upon  the  os  uteri,  may  cause  irritation 
and  consequent  rigidity. 

TREATMENT  OF  RIGIDITY. 

By  what  means  can  the  accoucheur  properly  expe- 
dite the  delivery  under  such  circumstances  ?  By  such 
medical  treatment  as  may  diminish  the  vital  tone.  If 
the  stomach  be  loaded  with  impurities,  gentle  eme- 
tics, washing  out  the  stomach,  &c.  Much  may  be 
done,  by  acting  on  the  bowels  by  the  warm  enemata, 
purgatives,  with  castor  oil,  &c.     Bleeding  is  very  use- 


OF   THE    LYING-IN    CHAMBER.  233 

ful,  particularly  if  the  patient  is  febrile.  After  bleeding, 
nauseating  diaphoretics,  &c.,  warm  injections,  warm 
fomentations  to  the  vulva,  favor  relaxation.  Advan- 
tage will  be  derived  from  keeping  the  patient's  mind 
calm  and  confident.  Anti-spasmodics,  as  assafoetida, 
camphor,  &c. ;  even  laudanum  may  be  beneficially 
employed  in  some  cases.  As  local  adjuvants,  the 
ointments  of  belladonna,  stramonium,  &c.,  may  be  ap- 
plied to  the  OS  uteri ;  anodyne  enemata,  from  sixty  to 
one  hundred  drops  of  laudanum,  may  be  given  at  once, 
after  the  bleeding,  or  purging,  &c. 

Is  it  often  necessai-y  to  divide  the  bands  or  cica- 
trices, to  overcome  the  constriction?  It  is  rarely  ne- 
cessary, in  the  cicatrices  or  adhesion  of  the  vagina  or 
perinaeum,  and  scarcely  ever  in  cases  of  rigidity  of 
the  OS  uteri,  if  proper  medical  or  constitutional  means 
are  resorted  to. 

What  danger  would  be  involved  in  the  division  of 
the  OS  uteri,  under  such  circumstances  ?  Extension 
of  the  incisions  to  a  degree  equal  to  a  dangerous  lace- 
ration of  the  uterus. 

IRREGULAR  CONTRACTIONS  OF  THE  UTERUS. 

May  labor  be  complicated  or  retarded  by  irregular 
contractions  of  the  uterus  ?  It  may  to  a  greater  or 
less  degree. 

How  are  these  irregular  contractions  diagnosticated  ? 
By  the  woman  feeling  the  pain  in  one  particular  spot, 
and  by  the  want  of  expulsive  effort. 

Where  may  these  spasmodic  contractions  occur  ?  In 
various  points,  as  the  body,  fundus,  and  orifice  of  the 
uterus. 

Why  do  we  rarely  have  spasmodic  contractions  in 
the  OS  uteri,  in  cases  of  regular  presentation  of  the 
vertex  ?  Owing  to  the  fact,  that  the  orifice  does  not 
embrace  the  neck  of  the  child,  in  consequence  of  the 
manner  in  which  its  chin  is  applied  to  the  thorax. 

May  the  internal  os  uteri,  become  spasmodically  con- 
tracted ?  It  is  believed  by  some  accoucheurs  that  it  may. 


234  MEDICINE    AND     SURGERY 

What  effect  has  this  upon  the  advancement  or  re- 
tardation of  the  child  ?  The  child  descends  to  the 
superior  strait,  during  an  expulsory  effort,  and  re- 
cedes at  once,  when  the  voluntary  powers  become  sus- 
pended. 

TREATMENT. 
What  is  the  proper  practice  in  this  case  ?  Vene- 
section, anodyne  injections,  &c.,  to  suspend  the  irregu- 
lar actions  of  the  uterus.  Avoid  turning  and  forcible 
delivery  merely  because  the  delivery  is  delayed  on  this 
account. 

CONVULSIONS. 

Are  convulsions  during  parturition  ever  dependent 
upon  rigidity  ?  There  is  much  reason  to  believe  they 
are  sometimes  dependent  upon  this  cause,  as  in  the  un- 
availing effort  at  delivery,  the  brain  becomes  the  seat 
of  such  degree  of  congestion,  as  determines  irregular 
or  spasmodic  contractions  of  the  muscular  system. 

Why  do  you  call  them  puerperal  convulsions  ? 
Merely  because  the  woman  affected,  is  in  a  pregnant, 
or  puerperal  state. 

Do  you  consider  them  different  from  convulsions 
which  may  occur  in  unimpregnated  women  ?  They  do 
not  differ  essentially  from  those  which  may  attack  un- 
impregnated women,  or  even  nervous  men. 

CLASSIFICATION  OF  PUERPERAL  CONVULSIONS. 

How  many  varieties  of  these  convulsions,  do  you 
generally  recognize  ?    Two  ;  hysterical  and  apoplectic. 

Which  is  the  most  frequent  variety?  The  apo- 
plectic. 

Which  is  the  least  dangerous  ?  The  hysterical 
variety. 

Upon  what  does  the  latter  variety  most  frequently 
depend?     Irritability  of  the  nervous  system. 

.      SYMPTOMS  OF  HYSTERIC  PUERPERAL  CONVULSIONS. 
What  are  the  general  symptoms  of  this  variety  of  the 


OF   THE    LYING-IN    CHAMBER.  235 

affection  ?     They  are  similar  to  the  higher  grades  of 
hysterical  convulsions  in  unimpregnated  women. 

What  effect  have  these  convulsions  upon  the  labor  ? 
They  usually  suspend  it,  inasmuch  as  there  appears 
to  be  a  sort  of  metastasis  of  muscular  contraction  of 
the  uterus  to  that  of  the  body  generally. 

SYMPTOMS  OF  THE  APOPLECTIC  PUERPERAL  CON- 
VULSIONS. 

What  are  the  symptoms  of  the  apoplectic  variety 
of  convulsions  ?  Those  of  congestion ;  mostly  pain 
in  the  head,  sometimes  intense  in  some  one  spot ;  there 
is  loss  of  vision,  perversion  of  the  hearing,  &c.,  pulse 
full,  slow  and  apoplectic.  Muscles  of  face  much 
affected ;  sibilating  noise ;  frothing  at  the  mouth ; 
convulsion  of  the  anterior  muscles  of  the  face  and 
body ;  the  patient  sometimes  falls  into  a  comatose 
state,  and  remains  so,  until  another  convulsion  comes 
on,  though  sometimes  she  promptly  recovers. 

What  is  the  cause  of  these  convulsions  during 
labor  ?  They  are  supposed  to  depend  upon  the  vio- 
lence of  the  uterine  and  general  expulsive  effort  react- 
ing on  the  brain. 

What  are  the  usual  post  mortem  appearances  in 
cases  of  these  convulsions  ?  Congestion  of  numerous 
vessels  in  the  brain  and  its  coverings,  with  serous,  or 
sanguineous  effusion. 

Are  there  some  cases  in  which  death  occurs,  with- 
out any  effusion,  or  apparent  lesions  of  the  brain  ? 
There  are  ;  and  this  fact  is  calculated  to  lead  to  the 
conclusion,  that  the  convulsions  may  depend  upon 
some  other  cause  than  determination  of  blood  to  the 
nervous  pulp  within  the  cranium. 

What  effect  have  these  convulsions  upon  gestation  ? 
Women  who  have  these  convulsive  movements  during 
pregnancy  are  liable  to  have  the  fetus  die  in  utero, 
or  to  abort  it  before  it  is  completely  developed. 

What  effect  has  gestation  upon  the  convulsions  ? 
Though  pregnancy  is  not   always  directly  a  cause  of 


286  MEDICINE   AND    SURGERY 

these  morbid  movements,  yet  the  woman,  in  some  in- 
stances, is  subject  to  have  them  occasionally  while 
pregnant,  or  a  repetition  of  them,  until  the  child  is 
delivered  either  at  term  or  prematurely. 

Are  the  pains  usually  suspended  upon  the  occur- 
rence of  convulsions  ?  When  convulsions  occur  during 
labor,  the  regular  contractions  of  the  uterus  become 
suspended — a  mere  fluttering  kind  of  movement  is 
observed. 

TREATMENT  IN  CASE  OF  CONVULSIONS. 

What  are  you  to  do  in  reference  to  the  condition 
of  the  uterus  ?  Let  it  alone  in  niost  cases,  especially 
during  the  first  stage  of  labor.  Attend  to  the  nerv- 
ous and  vascular  systems  alone,  and  allow  the  uterus 
to  take  care  of  itself.  This  it  will  usually  do,  if  the 
tranquillity  of  the  nervous  and  general  muscular  sys- 
tem can  be  restored.  If  the  labor  have  advanced  to 
the  second  stage,  you  may  sometimes  deliver  with  the 
forceps,  if  the  head  be  low  in  the  pelvis. 

How  should  you  treat  the  apoplectic  variety  of 
these  convulsions  ?  Bleed,  twenty,  thirty,  forty  or  fifty 
ounces,  until  you  empty  the  blood  vessels  and  relieve 
the  plethora  ;  then  resort  to  the  usual  treatment  for 
apoplexy — cold  to  the  head — mercurial  cathartics, 
&c., — active  enemata — cups  and  leeches  may  some- 
times be  employed  after  one  free  bleeding.  When 
vascular  depletion  has  been  carried  sufficiently  far, 
sinapisms,  blisters,  &c.,  may  be  used  as  revulsives  or 
counter-irritants.  When  the  congestion  is  thus  re- 
lieved, opium  or  camphor  may  be  given  in  combina- 
tion with  calomel  and  ipecacuanha,  and  after  the  system 
shall  have  been  properly  reduced,  and  the  disease 
controlled,  mild  tonics,  as  valerian,  &c.,  may  be  ad- 
ministered. 

Should  you  interfere  with  the  process  of  gestation, 
supposing  it  be  not  complete  ?  We  think  not,  at  least 
not  until  after  all  the  usual  means  of  treatment  have 
been  fully  employed.     Should  the  convulsions  persist 


or    THE    LYINGIX    CHAMBER.  287 

under  such. circumstances,  we  might  consider  the  pro- 
priety of  premature  delivery. 

Are  some  patients  incident  to  continued  effects  of 
convulsions,  or  rather  to  a  state  approaching  that 
which  results  in  convulsions  ?  Yes ;  there  often 
remains  a  disposition,  for  congestion  of  the  large 
blood  vessels,  with  great  irritability  of  the  nervous 
system. 

What  is  the  treatment  proper  for  such  a  state  ? 
Revulsion  by  moderate  bleeding,  and  the  use  of  sina- 
pisms, &c. 

INERTIA  OF  THE  UTERUS. 

What  do  you  mean  by  the  phrase  inertia  of  the 
uterus?  That  condition  of  the  organ  in  which  it 
does  not  obey  the  instinct  of  contraction. 

What  are  its  general  causes  ?  During  the  first 
stage  of  labor,  it  may  depend  upon  plethora  in  the 
uterus.  Sometimes  it  depends  upon  a  transference 
of  the  irritation  from  the  uterus  to  the  brain,  heart, 
lungs,  &c. — sometimes  upon  some  diseases  of  the 
uterus,  or  general  debility  from  phthisis,  uterine  he- 
morrhages, &c. 

May  not  inertia  occur  while  the  uterus  possesses 
a  sufficient  amount  of  power  ?  It  may,  and  then  it 
merely  requires  to  be  stimulated  into  action. 

TREATMENT  OF  INERTIA. 

How  are  you  to  manage  a  case  of  inertia  of  the 
uterus  ?  During  the  first  stage  of  labor,  but  little 
interference  is  necessary :  we  should  endeavor  to 
ascertain  the  causes  of  the  inertia — if  plethora, 
bleed — if  constipation,  purge — if  from  irregular  dis- 
tribution of  the  nervous  influence,  give  those  medi- 
cines calculated  to  act  upon  and  regulate  the  nervous 
system. 

How  would  you  stimulate  the  uterine  fibres  mo- 
derately ?     By  friction,  by  cathartics,  by  warm  teas, 


238  MEDICINE    AND    SURdERY 

How  in  the  second  stage?  If  the  uterus  be  dis- 
tended, rupture  the  membranes,  provided  the  os  uteri 
be  sufficiently  dilated  ;  then  act  slightly  upon  the  os 
tincse  with  the  finger,  by  a  slight  traction  in  differ- 
ent directions.  If  this  did  not  succeed  we  would 
administer  the  ergot. 

ERGOT. 

Would  you  consider  ergot  as  a  dangerous  remedy? 
Highly  so,  if  not  very  judiciously  resorted  to ;  but 
very  important  and  useful  in  proper  cases. 

Why  has  it  probably  been  productive  of  such  fatal 
effects  in  practice?  Because  it  has  been  resorted  to 
in  cases  when  the  advancement  of  the  child  was  op- 
posed by  vital  resistances,  as  before  the  os  uteri  or 
the  perinseum  was  sufficiently  relaxed  to  admit  of 
ready  egress  of  the  fetus,  forcibly  compressed  by  the 
ergotic  contraction  of  the  uterus.  Furthermore,  it 
has  been  productive  of  immense  evil  when  adminis- 
tered in  cases  of  mal-position  of  the  child,  or  when 
there  has  been  deformity  or  deficiency  of  amplitude 
in  the  pelvis. 

Under  what  circumstances  can  you  administer  it 
with  propriety  ?  Dilatation  or  relaxation  of  all  the 
soft  parts,  favorable  positions,  or  presentations ;  ab- 
sence of  any  mechanical  resistance  at  either  of  the 
straits  of  the  pelvis.  It  is  rarely  proper  to  administer 
it  in  cases  of  first  pregnancy,  because  of  the  tenacity 
of  the  vital  resistances  in  these  cases. 

What  are  the  usual  effects  of  the  ergot  upon  the 
uterine  fibre  ?  It  stimulates  it  to  tonic  contraction, 
by  which  nearly  every  portion  of  it  acts  in  the  direc- 
tion to  diminish  its  capacity,  and  the  whole  organ, 
therefore,  acts  with  great  and  persistent  force  upon 
the  body  within  its  cavity. 

ERGOT  SOMETIMES  ITSELF  INERT. 

Does  the  ergot  sometimes  fail  in  producing  such 
effect?     It   does   so  sometimes,  owing   either  to  the 


OF   THE    LYIXG-IN    CHAMBER.  239 

idiosyncracy  of  the  patient,  or  to  the  bad  quality  of 
the  article. 

Should  you  ever  give  ergot  in  any  cases  of  me- 
chanical obstruction  in  labor  ?  There  is,  probably, 
no  case  of  this  kind  in  which  the  use  of  ergot  would 
be  proper. 

HEMORRHAGE  AT    OR   SHORTLY  AFTER   THE    TERMINA- 
TION OF  LABOR. 

To  how  many  varieties  of  hemorrhage  may  the  pa- 
tient be  incident  in  the  latter  stage  of  labor,  from 
inertia  of  the  uterus  ?  Two,  the  open,  and  the  con- 
cealed hemorrhage. 

What  is  the  distinction  between  these  two  varie- 
ties ?  In  the  first,  the  blood  flows  from  the  uterus 
through  the  vagina,  nearly  as  fast  as  it  escapes  from 
the  orifices  of  the  uterine  vessels,  and  is  mostly 
readily  discerned  and  announced  by  the  patient  her- 
self, or  may  without  any  difficulty  be  detected  by  the 
nurse  or  personal  attendant.  In  the  other  variety, 
on  the  contrary,  the  patient  may  not  evince  the 
slightest  consciousness  of  the  existence  of  the  efi'usion 
from  the  patulous  orifices,  nor  can  the  nurse  or  phy- 
sician become  persuaded  of  its  occurrence  until  the 
patient  has  fainted,  the  pulse  has  failed,  or  become 
enfeebled  at  the  wrist,  or  her  uterus  has  been  found 
to  have  reacquired,  in  part,  or  entirely,  the  size  of  the 
recent  gravidity. 

Which  of  these  two  varieties  is  most  alarming,  and 
dangerous  ?  The  first,  usually  most  alarms  the  pa- 
tient, by  the  consciousness  of  its  occurrence,  and  the 
apprehension  of  dangerous  consequence  upon  it — 
while  the  latter  or  concealed  variety  most  per- 
turbs the  physician,  because  it  may  have  reached  a 
point  of  extreme  danger  before  he  has  been  apprised 
of  it,  or  had  it  in  his  power  to  control  it. 


240 


MEDICINE  AND  SURGERY 


MANAGEMENT  OF  HEMORRHAGE. 

What  is  the  first  object  of  the  practitioner  in  cases 
of  hemorrhage  from  the  uterus  ;  in  the  third  stage  of 
labor  ?  To  excite  the  tonic  contractions  of  the  or- 
gan, and  thus  cause  it  to  close  up  the  open  venous 
orifices. 

How  should  he  eff'ect  this  ?  By  friction  ;  by  knead- 
ing, as  it  were,  upon  the  uterus ;  by  the  application  of 
a  cold  hand,  cloth,  or  sponge,  or  plate  of  snow,  or 
ice  upon  the  pubic  region  ;  by  powerful  compression  ; 
by  the  passage  of  a  hand  into  the  cavity  of  the  uterus ; 
by  introducing  within  it  a  sponge  saturated  with  vine- 
gar, or  by  passing  up  a  peeled  juicy  lemon  ;  allow- 
ing these  acid  vehicles  to  remain  until  expelled  by 
the  contraction  of  the  uterus,  &c. 

Would  you  give  ergot  in  any  of  these  cases  ?  It 
might  be  given  if  at  hand,  particularly  if  in  the  form 
of  tincture,  though  it  is  the  experience  of  some  prac- 
titioners that  it  rarely  acts  in  cases  of  great  prostra- 
tion from  hemorrhage. 

HOW  TO  PREVENT  IT  BY  ANTICIPATION. 

Knowing  your  patient  subject  to  atony  and  he- 
morrhage in  the  last  stage  of  labor,  would  you  give 
the  ergot  in  anticipation  ?  We  would  give  it  just  as 
the  child  was  about  to  be  extruded. 

Would  you  at  once  remove  the  placenta  from  the 
vagina,  or  leave  it  in  until  the  hemorrhage  is  arrested  ? 
Pass  our  hand  beyond  the  placenta,  remove  the  coa- 
gula  we  may  meet  with,  and  as  the  uterus  contracts 
allow  it  to  come  away. 

What  general  rule  should  you  observe  in  reference 
to  the  mode  of  preventing  this  accident?  See  that 
the  different  stages  of  labor  go  on  regularly. 

Bhould  you  remain  by  your  patient  until  she  reacts 
after  her  labor  ?  You  should  never  leave  her  till  you 
have  witnessed  this  state. 

Suppose  your  patient  arrives  at  the  term  of  gesta- 


OF   THE   LYIXG-IX   CHAMBER.  241 

tion,  and  she  becomes  greatly  prostrated  by  phthisis, 
pulmonary  hemorrhage,  &c.,  would  you  think  proper 
to  bring  on  labor  and  expedite  her  delivery  ?  If  we 
can  arrest  the  cause  of  the  exhaustion,  we  ought  to 
wait  till  term  ;  but  if  she  be  constantly  sinking,  it  is 
thought  better  to  deliver  promptly,  but  cautiously, 
while  the  patient  is  yet  capable  of  furnishing  the 
means  of  hematosis  to  the  child. 

Suppose  your  patient  be  affected  by  syncope  during 
labor  or  pregnancy,  should  you  generally  be  alarmed? 
Not  generally ;  we  are  rather  to  regard  it  as  depend- 
ing upon  a  want  of  regular  distribution  of  the  nervous 
influence,  but  usually  easily  managed  by  the  use  of 
cordials  and  aromatic  stimuli,  applied  externally,  or 
administered  internally  as  the  case  may  require. 

CONCEALED  HEMORRHAGE. 

What  is  the  usual  process  by  which  occult  hemorr- 
hage occurs  ?  The  blood  which  escapes  from  the  pa- 
tulous orifices  of  the  vessels  on  the  inner  surface  of 
the  uterus,  becomes  coagulated  at  the  os  tincse,  which 
it  plugs  up — the  hemorrhage,  thus  prevented  from 
escaping  externally,  goes  on,  and  the  tonic  contrac- 
tion of  the  uterus  being  absent,  it  distends  the  uterus, 
and  the  quantity  thus  abstracted  from  the  system  be- 
comes so  great  that  the  patient  dies  at  once,  or  falls 
into  a  state  of  syncope,  from  which  she  can  be  revived 
only  by  the  most  prompt  measures. 

What  influence  has  the  presence  of  coagula  in  the 
vagina  in  this  case  ?  It  appears  to  paralyse  the  ute- 
rus, and  thus  prevent  it  from  closing  up  its  venous 
orifices  by  tonic  contraction. 

What  should  be  done  in  such  cases  ?  Promptly 
and  resolutely  carry  a  hand  through  the  vagina  into 
the  orifice,  neck  or  body  of  the  uterus,  break  up  the 
coagulum,  let  the  fragments  pass  by  the  palm,  wrist 
and  arm,  detaining  these  in  the  cavity  into  which  they 
had  been  introduced,  until  the  contractions  of  the 
uterus  expel  them. 

21 


242  MEDICINE    AND    SURGERY 

How  should  the  opposite  hand  be  employed  during 
this  time  ?  Most  assiduously  in  promoting  the  con- 
traction of  the  uterus  by  pressure,  or  the  application 
of  cold,  or  both,  upon  the  abdomen. 

What  influence  would  galvanism  probably  have  in 
promoting  the  contraction,  arresting  hemorrhage  and 
preventing  its  recurrence.  If  a  suitable  battery  were 
at  hand  it  would  be  worthy  of  a  trial  in  cases  of  great 
atony  of  the  uterus. 

LABOR  COMPLICATED  BY  LESIONS   OF  STRUCTURE  OF 
THE  UTERUS— RUPTURE  OF  THE  UTERUS. 

To  what  particular  accident  is  the  uterus  liable, 
during  the  parturient  effort  ?  Lesion  of  its  structure, 
either  partially  or  entirely,  that  is,  there  may  be  a 
separation  of  some  portion  of  its  tissue,  or  the  rupture 
may  extend  through  its  entire  substance  involving  the 
peritonaeum. 

What  are  the  symptoms  of  rupture  of  the  uterus  ? 
A  sudden  suspension  of  the  alternate  contractions, 
great  prostration  of  strength,  hurried  or  gasping  respi- 
ration, rapid  pulse,  &c. 

What  are  the  consequences  of  this  accident  ?  They 
are  dependent  upon  the  extent  of  the  accident :  the 
patient  may  recover  from  a  partial  rupture,  but  when 
it  is  complete,  the  result  is  almost  always  fatal. 

What  are  the  indications  of  the  treatment  in  this 
case  ?  If  the  rupture  take  place  in  the  first  stage  of 
the  labor,  gastronomy  should  be  resorted  to  imme- 
diately, with  a  hope  to  sa-ve  the  child,  but  if  in  the 
second  stage,  version  by  the  feet,  or  delivery  by  the 
forceps,  should  be  promptly  effected. 

Suppose  the  child  has  escaped  into  the  cavity  of 
the  abdomen,  what  should  you  do  ?  Placing  one  hand 
externally  over  the  situation  of  the  child,  we  should 
pass  the  other  into  the  pelvis,  and  through  the  rent  in 
the  uterus  endeavor  to  find  the  feet,  and  bring  them 
down. 

What  if  the  rupture  should  occur  in   the  vagina,  is 


OF   THE   LYING-IN   CHAMBER.  243^ 

your  chance  of  delivery  greater  ?  It  is,  inasmuch 
as  in  such  case  the  opening  is  not  shut  up  by  con- 
traction. 

Would  you  think  you  might  resort  promptly  to  the 
operation  of  gastronomy,  if  you  could  not  deliver  the 
child  through  the  natural  passages  ?  That  would  be 
the  only  proper  course. 

Does  this  rupture  ever  arise  from  rigidity  of  the  os 
uteri  or  perinseum,-  while  other  parts  are  subject  to 
ramollissement  ?     It  is  believed  that  it  does. 

Under  what  circumstances  would  you  use  the  for- 
ceps or  crotchet  in  such  an  accident  ?  In  case  the 
head  was  still  in  the  cavity  of>  the  pelvis,  though  the 
body  had  passed  into  the  cavity  of  the  abdomen. 

BLUNDELL'S  INSTRUCTIONS. 
What  are  Blundell's  instructions  to  accoucheurs  in 
reference  to  their  duties  in  this  momentous  accident  ? 
He  tells  them  that  the  management  of  these  cases,  so 
far  as  they  admit  of  management,  may  be  given  in  a 
few  words.  If  the  child  have  been  thrown  into  the 
world,  the  accoucheur  has  nothing  to  do  but  to  treat 
the  patient  on  the  ordinary  principles  of  medicine  and 
surgery.  If  disruption  occurring  it  is  incarcerated 
amongst  the  bones,  so  as  to  remain  fixed  in  the  pelvis, 
though  the  body  lies  forth  through  the  rupture,  you 
may  then,  properly  enough,  apply  a  pair  of  forceps  ; 
in  this  way  superseding  the  necessity  of  the  operation 
of  turning.  When  lacerations  of  the  womb  occur,  how- 
ever, it  will  generally  be  .found  that  the  child  enters 
the  peritoneal  sac,  the  placenta  immediately  following 
it,  the  womb  emptying  itself  as  effectually  as  when,it 
expels  the  ovum  through  the  pelvis.  Now,  by  exami- 
nation, this  ventral  lodgement  of  the  pelvis  is  easily 
made  out,  and  when  ascertained,  it  then  becomes  your 
office  to  remove  the  coat,  raise  the  sleeve  of  your 
shirt,  to  lubricate  the  hand,  and  to  carry  it  resolutely, 
but  gently  and  steadily  along  the  vagina  and  through 
the  ruptured  opening,  so  as  to  enter  the  cavity  of  the 


244  MEDICINE   AND    SURGERY 

perltonfPAim,  lay  hold  of  the  feet  and  bring  away  the 
child  by  the  operation  of  turning.  Beware  of  grasp- 
ing the  intestines  and  pulling  them  away  with  the  feet. 
Provided  no  injury  be  inflicted  on  the  mother,  the 
sooner  the  operation  of  turning  is  commenced  and 
completed  the  better,  because  if  the  child  is  left  long 
in  the  peritonseal  sac,  it  perishes  in  consequence  of  the 
suspension  of  the  function  of  the  placenta,  which  lies 
detached  among  the  intestines  ;  but  if  the  fetus  is  re- 
moved promptly,  there  is  a  reasonable  hope  that  it 
may  be  abstracted  alive,  and  if  no  violence  be  em- 
ployed, promptitude  of  delivery  may  also  facilitate 
the  recovery  of  the  mother.  The  child  taken  away, 
the  placenta  is  to  be  extracted  also ;  the  operator  be- 
ing careful  not  to  leave  any  part  of  it  behind,  and  in 
this  abstraction  great  care  must  be  taken  that  you  do 
not  draw  down  any  other  parts  together  with  the 
after-birth,  and  more  especially  the  intestines.  Let 
the  mind  in  these  dreadful  emergencies  be  kept  tran- 
quil and  unshaken ;  unless  you  are  undisturbed  and 
settled  steadily  upon  obstetric  principles,  you  are  unfit 
to  act.  If  you  are  unequal  to  the  duty,  give  up  the 
management  of  the  case  altogether,  and  send  for  fur- 
ther assistance.  Do  not  mislead  yourselves  with  the 
notion,  that  these  cases  are  desperate,  and  therefore 
it  matters  little  what  is  done  by  the  patient.  One  re- 
covery I  have  witnessed,  and  there  are  others  on  re- 
cord. 

What  is  the  history  and  his  mode  of  acting  in  the 
case  which  he  saw  recover  ?  "A  woman  in  the  neigh- 
borhood of  Guy's  Hospital,  had  a  contraction  of  the 
pelvis — I  was  called  in,  in  consequence  of  a  collapse 
of  the  strength,  and  when  I  examined,  I  found  the 
child  lying  in  the  peritonreal  sac,  distinct  from  the 
uterus,  the  aperture  of  which  was  contracted,  and  I 
found  further,  a  large  transverse  rent  opposite  the 
bladder.  Well,  in  this  case,  agreeably  to  the  rule,  I 
determined  to  turn,  and  for  this  purpose  introducing 
my  hand  into  the  peritonaial  sac,  I  perceived  the  intes- 


OF   THE    LYING-IN    CHAMBER.  245 

tines,  felt  the  beat  of  the  large  abdominal  arteries, 
touched  the  edge  of  the  liver,  and  ultimately  reach- 
ing the  feet  of  the  child,  I  withdrew  it  by  the  opera- 
tion of  turning,  subsequently  abstracting  placenta 
and  membranes,  the  woman  recovering  in  a  few  weeks 
afterwards.  About  five  years  after  the  recovery,  I 
saw  her  not  so  vigorous  as  before  the  accident,  but 
nevertheless  tolerably  well.  On  very  careful  exami- 
nation at  this  time,  the  os  uteri  was  found  to  present 
the  natural  character,  and  not  a  vestige  of  the  cica- 
trice was  discoverable  in  the  vagina  any  where  above 
or  below ;  the  rupture  therefore  had  been  above  in 
the  uterus  itself.  When,  in  this  case,  my  hand  was 
introduced  to  turn  the  fetus,  the  womb,  large  as  a 
child's  head,  was  felt  lying  upon  the  promontory  of 
the  sacrum,  above  and  behind  the  rent." 

PROLAPSUS  AND  PROCIDENTIA  OF  THE  UTERUS. 

Are  there  any  cases  recorded  in  which  the  pro- 
lapsus of  the  uterus  has  continued  to  \h.e  end  of  ges- 
tation ?  In  the  late  valuable  edition  of  Professor 
Meigs'  work,  *'  Obstetrics,  the  Science  and  the  Art," 
is  related  a  case  under  the  care  of  Dr.  W.  S.  Haines, 
the  present  resident  physician  of  the  Blockley  Hos- 
pital, Philadelphia,  in  which  the  prolapse  of  the  va- 
gina was  so  great  as  to  protrude  some  distance  be- 
yond the  vulva,  at  the  time  of  labor,  at  seven  and  a 
half  months  of  gestation.  Dr,  M.,  whose  entire 
work  should  be  carefully  read  by  every  student  and 
practitioner  of  obstetrics,  has  given  a  drawing  which 
he  considers  a  faithful  representation  of  the  condition 
alluded  to.  Several  instances  are  reported — one  by 
Dr.  Ashwell,  others  by  American  physicians,  in 
which  women  afflicted  with  complete  procidence  of 
the  gestative  organ,  have  continued  in  this  distress- 
ing condition  till  delivered  at  or  near  full  time. 

Does  this  condition  of  the  uterus  necessarily  inter- 
fere with  easy  delivery  when  the  uterine  contractions 
are  established  ?  Although  it  has  been  supposed  that 
21* 


246  MEDICINE   AND    SURGERY 

the  principal  obstacle  to  the  easy  completion  of  the 
second  stage  of  labor  was  to  be  found  in  the  curva- 
tures of  the  pelvis  and  the  resistance  of  the  vagina 
and  perinoeum,  yet  Ashwell  had  recourse  to  the  for- 
ceps, and  other  gentlemen  to  embryulcia,  for  the  com- 
pletion of  the  delivery  of  the  fetuses  in  their  respec- 
tive cases.  It  is  not  easy  to  conceive  that  instrumen- 
tal deliveries  must  be  necessary  in  all  cases  of  proci- 
dentia of  the  uterus. 

INVERSION  OF  THE  UTERUS  AFTER  DELIVERY. 

What  is  another  marked  consequence  of  atony  of 
the  uterus  occurring  during  the  second  and  third 
stages  of  labor  ?     Inversion  of  the  uterus. 

What  are  the  usual  causes  of  this  accident  ?  Firstly, 
great  weight  of  the  placenta.  Secondly,  .too  early 
and  too  forcible  expulsive  efforts  of  the  mother. 
Thirdly,  the  continued  and  forcible  bearing  down  of 
the  mother  after  extrusion  of  the  child,  &c.  Fourthly, 
Dewees  and  some  others  think  it  may  depend  upon 
irregular  contractions  of  the  fundus,  &c. 

DEGREES  OF  INVERSION. 

What  are  the  degrees  of  inversion  of  the  uterus  ? 
Three  are  generally  recognized  in  this  country,  viz.  ; 
first,  simple  depression  of  the  fundus — second,  por- 
tion of  the  fundus  passed  the  orifice — third,  com- 
plete inversion,  in  which  the  whole  organ  is  turned 
inside  out. 

What  degree  of  inversion  causes  the  most  serious 
consequences,  the  complete  or  incomplete  ?  The  in- 
complete. 

Why  is  this  so  ?  Because  in  this  case  the  portion  with- 
in the  neck  is  strangulated,  and  the  circulation  is  im- 
peded through  it,  and  hence  venous  hemorrhage  is  kept 
up,  inflammation  and  sloughing  may  also  occur  from 
this  cause,  while  in  cases  of  complete  inversion,  all 
contraction  is  obviated,  and  although  more  or  less  he- 


OF   THE    LYING-IN    CHAMBER.  247 

morrhage   occurs  frequently  or  constantly,  yet  there 
are  no  consequences  of  strangulation  in  the  part. 

DIAGNOSIS  OF  INVEilSION. 

What  is  the  diagnosis  of  this  accident  ?  The  mo- 
ment of  its  occurrence,  the  patient  complains  of  a 
sudden  sinking  about  the  pelvic  region,  shrieks  out, 
becomes  faint,  &c.  Upon  applying  a  hand  at  the  va- 
gina, a  mass  of  greater  or  less  size,  depending  upon 
the  degree  of  the  inversion,  will  be  perceived  without 
or  wifliin  the  vulva,  or  perhaps  even  within  the  os 
uteri  itself,  if  it  be  merely  in  the  first  degree,  (though 
in  this  there  is  usually  less  sense  of  exhaustion.)  If 
it  be  external  to  the  os  uteri,  the  mass  presents  a 
rather  dense  structure,  with  a  soft,  spongy,  more 
or  less  rugose  surface,  not  necessarily  sensitive  to  the 
touch. 

How  can  you  distinguish  this  internal  surface  from 
a  polypus  tumor  ?  This  may  be  very  difficult  in  some 
cases,  but  generally  perhaps  the  surface  of  the  uterus 
is  more  rugose  than  that  of  the  polypus. 

May  the  practitioner  not  mistake  this  for  a  coagu- 
lum,  a  placenta,  or  a  presentation  of  another  fetus  ? 
This  would  require  care  in  his  physical  examination, 
but  then  with  these  the  patient  does  not  suffer  in  the 
same  manner. 

TREATMENT  OF  THE    INVERSION  OF  THE  UTERUS. 

Remembering  that  the  fundus  of  the  uterus,  which 
in  the  normal  condition  of  things,  is  uppermost  and 
at  the  farther  end  of  the  axis  of  the  organ,  is  now  the 
first  thing  to  be  seen  or  handled,  it  will  be  proper  to 
watch  for  the  absence  of  contraction,  and  taking  ad- 
vantage of  this  moment,  press  upon  its  centre  with 
the  points  of  the  fingers  of  the  hand  brought  into  a 
conical  form,  and  steadily  attempt  to  carry  it  up  along 
the  direction  of  the  axis  of  the  uterus  till  the  entire 
hand,  wrist,  and  part  of  the  arm  have  passed  through 
the  OS  uteri — even  though  it  should  be  necessary  to 


248  MEDICINE    AND    SURGERY 

carry  the  fundus  by  this  process  as  high  as  the  umbili- 
cus of  the  patient :  there  retain  it  until  a  violent  con- 
traction of  the  organ  expels  it.  Observing  carefully 
by  the  other  hand  now  to  be  applied  upon  the  hypo- 
gastrium,  that  the  contracting  and  diminishing  organ 
retains  its  proper  rotundity  ;  but  if  this  be  not  prac- 
ticable, desist,  and  leave  the  case  to  the  gradual  phy- 
siological changes  which  may  be  efiected  in  it,  to  adapt 
it  to  its  new  situation. 

How  are  cases  of  partial  inversion  to  be  managed  ? 
It  has  been  proposed  that  the  reposition  of  sucR  cases 
is  more  difficult  than  when  the  inversion  is  complete. 
Still  it  is  proper  to  attempt  it  by  the  means  indicated 
above,  and  if  this  fails,  to  seize  the  fundus  and  body, 
bring  them  entirely  down,  and  if  reduction  in  the  ab- 
sence of  contraction  be  not  then  easy,  leave  the  case 
to  subsequent  palliative  treatment,  till  the  hemorrhagic 
tendencies  are  subjected  to  a  healthy  standard. 

LABOR  COMPLICATED  WITH  INCAPACITY  OF  THE    NATU- 
RAL POWERS  TO  COMPLETE  EXPULSION  OF  THE  CHILD. 

May  it  occur  that  a  woman  may  be  well  formed, 
have  her  labor  come  on  at  time,  her  child  present 
either  pole  of  its  ellipse  favorably,  and  yet  be  incom- 
petent to  complete  its  birth  by  her  own  unaided 
power  ?  It  may  and  does  so  occur,  that  some  women 
whose  children  present  well,  or  whose  deviated  presen- 
tation has  been  rectified,  fail  of  ability  to  complete 
the  delivery  at  all,  or  not  without  the  most  exhausting 
eiforts. 

What  is  the  duty  of  the  accoucheur,  patient,  and 
society  under  such  circumstances  ?  It  is  the  duty  of 
the  accoucheur  to  exercise  a  prudent  judgment,  and 
a  high  intelligence,  as  to  the  nature  of  the  patient's 
condition  and  her  prospects  of  success,  or  otherwise 
in  the  effort  she  is  making,  to  give  her  the  full  benefit 
of  this  judgment  as  to  whether  she  will  or  will  not  be 
able  to  complete  the  delivery  safely  to  herself  or  infant 
by  her  own  unaided  powers,  frankly  to  inform   her  if 


OF   THE   LYING-IN    CHAMBER.  249 

he  believes  tins  impracticable,  itdvise  her  as  to  the 
means  of  assistance  which  science  and  ^rt  have  placed 
within  his  reach,  and  which  he  (if  he  have  been  pro- 
perly trained)  may  make  available  for  the  benefit  of 
herself  and  child.  It  is  the  duty  of  the  patient  to 
regard  the  counsel  which  a  properly  educated  physi- 
cian may  communicate  under  such  circumstances,  to 
ask  him  to  be  governed  in  his  conduct  towards  her  by 
the  dictates  of  his  matured  discretion ;  to  solicit  of  him 
such  interference  as  he  believes  her  case  to  require, 
and  to  submit  with  all  possible  calmness  and  confi- 
dence to  any  manual  or  instrumental  process  w^hich 
may  be  necessary  for  the  safe  conducfof  herself  and  her 
child  through  the  perils  to  which  either  or  both  may  be 
unfortunately  subjected  ;  and  furthermore,  it  is  the  duty 
of  society,  most  earnestly,  to  place  every  reasonable  fa- 
cility in  the  way  of  those  who,  from  promptings  of  hu- 
manity, or  even  of  self-interest,  enter  upon  the  study 
of  medicine  with  a  view  to  practise  the  art  upon  the 
afilicted  of  their  fellow  citizens;  facilities  for  ac- 
quiring a  thoroilgh  knowledge  of  the  principles  and 
rules  of  the  art,  to  hold  in  high  appreciation  those  per- 
sons who,  at  great  personal  sacrifice,  devote  them- 
selves to  such  responsible  and  care-wearing  services, 
to  encourage  and  sustain  them  by  their  kind  regards, 
and  by  substantial  tokens  to  evince  their  gratitude  to 
them  as  ministers  of  a  vocation  the  most  important 
which  man  can  exercise  towards  the  afilicted  of  his 
race,  and  particularly  to  those  cases  in  which  the 
lives  of  both  mother  and  child  are  in  jeopardy. 

INSTRUMENTAL  SURGERY.— CLASSIFICATION  OF 
OBSTETRIC  INSTRUMENTS. 

How^  are  the  instruments  used  in  obstetricy  classi- 
fied ?  1.  Those  which  do  not  injure  mother  or  child  : 
2.  Those  which  reduce  the  size  of  the  child,  for  the 
benefit  of  the  mother  :  3.  Those  which  subject  the  hfe 
of  the  mother  to  risk  with  a  view  to  save  the  child  alive. 

Of  what  do  these  instruments  consist  ?     The  vectis ; 


250 


MEDICINE    AND    SURGERY 


the  fillet;  the  Blunt  hook;  the  forceps;  the  perforator; 
the  crotchet ;  the  craniotomy  forceps  ;  and  the  cranial 
compressors. 

FORCEPS. 

What  obstetric  instrument  have  we  of  much  greater 
value  than  the  vectis  or  lever  ?     Forceps. 

What  do  these  forceps  represent  ?  A  pair  of  arti- 
ficial hands. 

What  is  the  composition  of  the  forceps  ?  Two  blades 
so  arranged  as  to  embrace  the  child's  head,  and  so  con- 
structed that  they  can  be  introduced  separately,  and 
then  locked  or  united  to  each  other,  as  shown  at  d,  d, 
and  a,  fisr.  94. 


Fig.  94. 


How  do  you  distinguish  the  forceps  by  the  length  ? 
Into  English  or  short  forceps,  as  shown  in  fig.  95, 
measuring  12  inches,  and  into  French,  or  long  forceps. 


Fig.  96. 


as  shown  in  fig.  96,  measuring    from  sixteen  to   nine- 
teen inches. 


OF   THE   LYING-m    CHAMBER.  ^51 

I 

What  forceps  are   thought  to  be  best,  French  or 
English  ?     Upon  the  whole,  the   French  forceps  pro- 
Fig.  96. 


perly  modified,  are  to  be  preferred ;  though  many  ex- 
cellent practitioners  prefer  the  English  or  short  for- 
ceps for  ordinary  cases  requiring  the  use  of  these 
instruments. 

What  is  the  mode  of  locking  in  the  English  forceps  ? 
At  the  handle  end  of  each  shank  is  a  deep  notch  into 
which  each  handle  of  the  instrument  is  neatly  adjusted, 
when  properly  locked,  as  seen  at  «,  fig.  96,  which  re- 
presents one  blade  of  an  English  forceps,  of  the  same 
length,  viz.  twelve  inches,  as  in  fig.  97,  but  on  a  larger 
scale. 


Fig.  97. 


What  is  the  mode  of  locking  the  French  or  Gemjan 
forceps  ?  There  is  a  conical  screw  pivot  near  the 
centre  of  one  blade  and  a  conical  notch  in  the  other, 
into  which  the  pivot  is  to  be  received.  Their  junction 
is  kept  secure  by  the  screw  carrying  down  the  cone  of 
the  pivot  into  the  conical  notch,  as  seen  at  a,  fig.  98, 
which  gives  a  profile  view  of  the  two  blades  as  locked. 

What  mode  of  junction  or  locking,  is  the  best  ? 
Perhaps  the  German,  or  French,  is  most  preferred. 

What  is  the  use  of  the  fenestra  in  the  blades  ?  To 
permit  some  portions  of  the  scalp  and  cranium,  as  the 


252  MEDICINE    AND    SURGERY 

parietal  protuberances  to  pass  tlirough  them,  and  thus 
enable   them  to  occupy  apparently   less  space  in  the 

Fig.  98. 


cavity  of  the  pelvis,  and  at  the  same  time  to  secure  a 
more  firm  grasp  of  the  head. 

To  what  part  of  the  pelvis,  is  the  use  of  the  short 
forceps  restricted?  Inferior  strait,  unless  perhaps  we 
except  those  contrived  by  Professor  D.  D.  Davis. 

From  what  parts  can  you  deliver  the  head  with  the 
long  forceps  ?  From  every  part  of  the  pelvis,  as  a 
general  rule. 

What  rule  have  you  for  the  application  of  force  in 
the  use  of  forceps  ?  Sufficient  to  overcome  the  resis- 
tance, if  possible,  without  injury  to  the  mother. 

To  what  part  of  the  child  are  the  forceps  to  be  ap- 
plied ?     Always  to  the  head. 

To  what  part  of  the  head  are  they  to  be  applied  ? 
To  the  sides,  in  all  cases  except  perhaps  one. 

What  is  that  one,  if  any  ?  In  occipito-iliac  positions, 
in  case  rotation  cannot  be  effected,  nor  the  blades 
carried  up  between  the  pubes  and  the  sacrum. 

To  which  diameter  of  the  head,  are  the  forceps  to 
be  applied  parallel  ?     The  occipito-mental  diameter. 

Should  you  give  the  mother  any  pain  in  the  intro- 
duction of  the  forceps  ?  None  other  than  to  excite 
the  contraction  of  the  uterus. 

Is  the  child's  head  liable  to  receive  some  slight  in- 
jury by  the  use  of  the  forceps  ?  This  is  in  some  cases 
unavoidable,  when  the  pelvis  is  small  or  deformed,  or 
the  head  badly  situated^  or  the  forceps  not  well  con- 
structed. 


OF  THE  LYING-IN   CHAMBER.  253 


CASES  FOR  THEIR  USE. 

In  what  particular  cases  are  the  forceps  indicated  ? 
When  there  is  too  much  resistance  to  be  overcome  by 
the  natural  powers,  or  when  the  powers  of  the  mother 
become  enfeebled  by  hemorrhage,  or  the  contractions 
irregular  by  convulsions,  &c. 

What  condition  of  the  os  uteri  must  exist,  before 
the  forceps  can  be  applied  ?  That  of  dilatation  ;  the 
first  stage  of  labor  should  be  complete  if  possible. 

Which  practice  is  preferable  for  young  practitioners, 
forceps,  or  version  by  the  feet,  in  cases  in  which  the 
head  is  still  at  the  superior  strait  ?  Version  by  the 
feet,  unless  well  trained  to  the  use  of -forceps. 

Is  it  well  for  you  to  be  provided  with  forceps  in 
cases  of  pelvic  presentations  ?  It  would  be  proper 
always  to  have  them  at  command  in  all  cases  of  pelvic 
presentations,  whether  original  or  rendered  such  by 
version,  that  the  delivery  of  the  head  may  be  effected 
as  rapidly  and  as  safely  as  possible. 

When  the  head  is  well  situated,  but  some  accident 
has  happened  to  the  mother,  should  you  resort  to  ver- 
sion by  the  feet  ?  Remembering  the  dangers  of  ver- 
sion, better  use  the  forceps  if  practicable. 

Suppose  the  head  has  passed  out  of  the  os  uteri, 
must  you  then  use  the  forceps  ;  instead  of  resorting  to 
version  ?  Version  would  then  be  out  of  the  question, 
and  the  whole  consideration  would  be  upon  the  use  of 
the  forceps. 

Is  it  important  you  should  diagnosticate  very  care- 
fully before  you  attempt  the  application  of  the  for- 
ceps ?  There  would  be  hazard  in  using  the  forceps 
without  correct  diagnosis. 

POSITION  OF  PATIENT  FOR  USE  OF  FORCEPS. 
IIpw  Avould  you  have  your  patient  placed  for  delivery 
by  the  forceps  ?     She  should  be  placed  as  for  the  op- 
eration of  version  by  the  feet. 

What  preparation  of  the  patient   would  vou  have 
2ii 


254  MEDICINE   AND    SURGERY 

made  before  you  operate  with  respect  to  the  bladder 
and  bowels  ?     They  should  be  carefully  evacuated. 

How  do  you  designate  the  blades  ?  Male  and  fe- 
male, or  left  hand  and  right  hand  blades. 

Which  is  male,  and  which  female  ?  The  male  blade 
has  the  pivot,  the  female  the  notch. 

What  relations  must  the  forceps  hold  to  the  pelvis 
as  they  withdraw  the  child's  head  through  the  lower 
strait  ?  Their  concave  edges  must  always  look  to  the 
pubes. 

MODE  OF  APPLICATION. 

What  are  the  diiferent  steps  in  the  introduction  of 
these  instruments  ?  In  the  first  place  the  consent  of 
the  patient  or  her  friends  should  be  obtained  for  the 
purpose,  after  a  due  explanation  of  the  necessity  and 
object  of  their  use.  The  patient  then  being  properly 
placed,  the  instruments  are  to  be  brought  to  a  suitable 
temperature  by  dipping  them  for  a  few  moments  in 
warm  water ;  the  male  blade  or  left  hand  blade,  is  to 
have  its  fenestrated  extremity  properly  lubricated,  the 
vulva  is  also  to  be  lubricated  as  well  as  the  right  hand. 
The  accoucheur  taking  his  station  between  the  limbs 
of  the  patient,  holds  the  male  or  left  hand  blade  in  his 
left  hand,  a  little  beyond  the  middle  towards  the  fen- 
estrated extremity,  in  the  same  manner  that  he  would 
hold  a  writing  pen.  The  dorsum  of  the  fingers  of  the 
right  hand  is  to  be  applied  to  the  left  labium  and  side 
of  the  vagina,  and  the  orifice  of  the  uterus  if  within 
reach.  The  handle  of  the  blade  being  carried  almost 
perpendicular  to  the  horizontal  line  on  which  the  pa- 
tient is  placed,  is  now  to  have  its  point  slided  cau- 
tiously along  the  palm  of  the  hand  and  the  fingers, 
gradually  approaching  a  parallel  with  the  patient's 
body,  until  the  blade  has  been  placed  by  the  side  of  the 
child's  head  in  the  direction  of  its  occipito-mental 
diameter.  The  handle  of  this  blade  is  then  to  be 
supported  by  an  assistant,  while  the  other  blade  is  to 
be  taken  in  the  right  hand,  and  its  fenestrated  extrem- 


OF   THE    LYING-IN    CIIAMBEE.  255 

ity  lubricated  as  the  other;  the  left  hand  is  now  to  be 
properly  prepared,  and  the  dorsum  of  its  fingers  ap- 
plied against  the  right  labium,  side  of  the  vagina,  and 
mouth  of  the  uterus  if  within  reach.  The  handle  of 
this  blade  is  then  to  be  carried  in  a  nearly  perpendi- 
cular direction  towards  tho  left  groin  of  the  patient, 
that  its  lower  point  may  be  slidod  along  the  palm  of 
the  left  hand  in  the  direction  of  the  axis  of  the  vagina, 
of  the  inferior  strait  of  the  cavity  of  the  pelvis,  and  if 
necessary,  the  superior  strait ;  as  this  movement  is 
effected ;  the  handle  is  of  course  correspondingly  de- 
pressed, till  it  comes  in  contact  with,  and  crosses  ob- 
liquely, the  blade  first  introduced,  and  the  points  of 
junction  brought  accurately  together ;  they  are  then 
to  be  locked. 

What  is  the  general  rule  in  reference  to  the  con- 
cave and  convex  edges  of  the  blades  ?  The  concave 
edges  are  to  look  towards  the  pubes,  and  the  convex 
edges  towards  the  hollow  of  the  sacrum. 

Should  you  always  keep  the  point  of  the  instru- 
ment against  the  head  of  the  child  ?  This  should 
always  cautiously  be  done  to  prevent  embracing  any 
of  the  soft  parts  of  the  mother  between  the  instru- 
ment and  the  child's  head. 

What  dangers  may  result  from  want  of  care  in  this 
matter  ?  The  inclusion  of  some  portion  of  the  mouth 
of  the  uterus,  or  even  penetration  into  the  abdomen, 
with  the  instrument. 

Is  it  warrantable,  in  any  case,  to  introduce  the 
forceps  before  the  head  has  cleared  the  os  uteri? 
Professor  Meigs,  who  is  high  authority,  says  it  is 
not. 

Is  there  any  danger  of  entangling  any  of  the  soft 
parts  in  the  fenestra  of  the  blades  ?     There  is. 

How  are  you  to  prevent  this  ?  By  carrying  up  the 
hand  as  a  guard  in  advance  of  the  blades. 

How  are  the  blades  to  approach  each  other  at  the 
lock  ?     In  nearly  parallel  lines. 

Should  the  blades  always  lock  readily  ?     Unless 


256  MEDICINE    AND    SURGERY 

they  do,  it  is  certain  that  the  head  is  not  accurately 
embraced. 

How  are  you  to  judge  whether  you  have  the  for- 
ceps properly  applied  to  the  child's  head  ?  By  their 
locking  readily,  while  the  blades  are  applied  in  the 
direction  of  the  occipito-mental  diameter  of  the  child's 
head,  as  indicated  by  the  position  of  the  occipital 
fontanelle  or  by  the  chin.  ^ 

Is  there  any  danger  of  passing  up  the  forceps  out- 
side  of  the  os  uteri?  There  is  great  danger  of  this 
accident  without  much  care  in  some  cases. 

What  test  have  you  that  this  has  occurred  ?  The 
complaint  of  the  patient  that  you  hurt  her. 

When  you  have  the  blades  locked,  should  you  make 
a  little  compression  and  traction  effort  ?  This  should 
be  done  in  order  to  bring  the  instruments  to  their 
proper  bearing,  and  to  ascertain  that  no  part  of  the 
mother  is  included. 

LIGATURE  OR  FILLET  ON  THE  FORCEPS  HANDLES. 

Should  you  apply  a  fillet  upon  the  forceps  in  all 
cases  ?  In  none  except  where  it  is  important  to  keep 
up  long  continued  and  firm  pressure. 

Under  what  circumstances  is  the  fillet  necessary  ? 
When  there  is  some  defect  of  size  of  pelvis,  or  too 
great  magnitude  of  the  child's  head. 

PRINCIPLE  OF  ACTION  WITH  THE  FORCEPS. 

What  is  the  modus  operandi  of  the  forceps  ?  Both 
as  levers  and  tractors. 

Should  the  forceps  be  regarded  as  a  double  lever  ? 
They  should. 

Where  is  the  common  fulcrum  ?     The  pivot. 

What  is  the  usual  centre  of  motion  of  these  levers 
during  the  effort  of  delivery?  The  trachelo-bregma- 
tic  diameter  of  the  child's  head. 

Should  you  be  particularly  careful  to  support  the 
perinaeum  in  delivery  by  the  forceps  ?  This  should 
be  regarded  as  an  important  object  of  attention. 


OF   THE    LYING-IN    CHAMBER.  257 

Is  it  proper  for  you  to  remove  the  forceps  as  soon 
as  the  head  escapes  through  the  inferior  strait  ?  This 
is  a  good  general  rule. 

FORCEPS  IN  FIRST  POSITION. 

In  what  direction  are  you  to  move  the  handles  of 
the  blades  ?  Frfltai  side  to  side  of  the  head,  and  al- 
ways from  handle  to  handle. 

Suppose  the  occiput  situated  obliquely  to  the  left  ace- 
tabulum, how  are  you  to  apply  the  male  blade  ?  Ele- 
vate the  handle,  pass  in  the  blade,  sweep  it  under  the 
top  of  the  head,  then  depress  the  handle  rapidly  to 
'bring  the  blade  to  the  side  of  the  head,  and  the 
pivot  will  look  towards  the  left  groin  of  the  mo- 
ther. 

How  should  you  pass  in  the  female  blade  ?  Pass 
it  firmly  into  the  cavity  of  the  pelvis  along  the  top 
of  the  child's  head,  then  by  insinuating  the  fingers 
under  the  convex  edge  of  the  blade,  depress  the  han- 
dle of  the  blade  to  sweep  it  over  the  parietal  protu- 
berance, and  allow  the  blade  to  lock  with  the  pivot 
to  the  left  groin  of  the  mother. 

Suppose  the  shoulders  become  arrested,  how  w^ould 
you  assist  their  delivery  ?  Continue  to  act  with  the 
forceps  upon  the  head ;  or  lay  them  aside  and  apply 
one  hand  behind,  and  the  other  in  front  of  the  neck, 
make  proper  traction  in  this  way ;  or  pass  up  the 
blunt  hook  into  one  axilla,  and  thus  make  proper 
traction  till  first  one  and  then  the  other  shoulder  is 
disengaged. 

Suppose  the  head  becomes  arrested  at  the  superior 
strait,  how  should  you  proceed  with  the  view  to  assist 
the  delivery  ?  Ascertain,  if  possible,  if  there  be  any 
deviation;  then  correct  it;  and  if  there  be  none,  or 
if  you  cannot  correct  it,  consider  what  further  action 
would  be  proper. 

Would  you  turn,  or  apply  the  forceps  ?     Turning 
would  be  safer,  unless  the  practitioner  have  much  ex- 
perience in  the  use  of  forceps. 
22* 


258  MEDICINE    AND    SURGERY 

Can  you  apply  them  easily  and  safely  at  the  supe- 
rior strait  ?  They  are  neither  easily  or  safely  ap- 
plied at  the  superior  strait,  and  should  not  be  applied 
at  that  point  under  any  circumstances,  unless  the 
practitioner  possess  great  dexterity  in  the  use  of  for- 
ceps. 

What  use  should  you  make  of  th^  hand  in  the  ap- 
plication of  the  blades,  admitting  you  attempt  to  use 
them  in  this  case  ?  Pass  it  into  the  cavity  of  the 
pelvis  till  it  comes  in  contact  with  the  head  suffi- 
ciently completely  to  protect  the  mother  from  injury. 

FORCJEPS  IN  SECOND  POSITION 

Are  there  any  greater  difficulties  in  applying  the 
forceps  in  the  second  position  of  the  vertex  than  in 
the  first  ?  When  the  occiput  is  towards  the  right 
acetabulum,  the  left  side  of  the  child's  head  to  which 
the  male  blade  is  to  be  applied,  is  so  closely  directed 
to  the  anterior  part  of  the  pelvis,  that  when  the  first 
or  male  blade  is  properly  introduced,  it  occupies  so 
much  of  the  anterior  commissure  of  the  vulva  as  to 
leave  insufficient  space  for  the  proper  introduction  of 
the  female  blade. 

How  is  this  difficulty  to  be  obviated  ?  First  pass 
in  the  male  blade  to  its  proper  situation :  having 
then  determined  what  this  is  by  the  actual  introduc- 
tion, retract  the  blade  by  reversing  the  motion  by 
which  it  was  passed,  till  it  is  opposite  the  left  ischium ; 
then  having  it  carefully  supported  by  an  assistant, 
introduce  the  female  blade  to  its  proper  situation 
along  the  right  sacro-iliac  junction.  This  blade  is 
still  in  front  of  the  male  blade ;  the  male  blade  is 
now  to  be  passed  up  to  its  original  situation  under 
the  ramus  of  the  left  pubis ;  when  if  all  is  right,  it 
will  lock  readily. 

FORCEPS  IN  POSTERIOR  POSITIONS. 

What  relation  docs  the  child's  head  hold  to  the 
forceps  in  the    posterior  positions   of    the    occiput? 


OF   THE    LYING-IN    CHAMBER.  259 

The  sinciput  then  corresponds  to   the   concave  edges 
of  the  blades. 

What  rule  have  we  for  the  direction  of  the  handles 
in  the  posterior  varieties  ?  As  the  occipital  extremity 
of  the  occipito-mental  diameter  is  directed  strongly 
backwards  in  these  cases,  it  is  necessary  to  depress  the 
handles  on  the  perinseum  to  secure  the  proper  portion 
of  the  head  within  the  blades. 

FORCEPS  IN  TRANSVERSE  POSITION  OF  THE  HEAD. 

Suppose  the  head  present  with  the  occiput  to  one 
ischium,  should  you  correct  the  deviation  by  the  vectis 
before  you  apply  the  forceps  ?  Yes^  if  at  all  practi- 
cable. 

Is  it  a  rule  in  obstetrics  not  to  apply  the  forceps 
with  one  blade  under  the  arch  of  the  pubes,  and  one 
over  the  perinaeum  or  coccyx  ?  It  should  never  be 
done,  if  possible  to  avoid  it. 

Should  we  always  attempt  to  correct  the  deviation 
by  the  vectis,  or  a  blade  of  the  forceps  used  as  a 
single  lever,  before  both  blades  are  used  for  tractors 
in  this  kind  of  presentation  ?  A  persevering  but 
judicious  effort  should  be  made  for  this  purpose,  in 
order,  if  possible,  to  prevent  the  necessity  of  applying 
them  over  the  occiput  and  face. 

Suppose  you  fail  in  all  reasonable  attempts  to  rotate 
the  head  into  an  oblique  position  ?  It  would  then 
seem  necessary  to  apply  the  instruments  either  over 
the  sides  *of  the  head  in  the  sacro-pubal  direction,  or 
over  the  sinciput  and  occiput  in  the  bis-ischiatic 
direction. 

If  you  decide  to  attempt  to  apply  the  instrument 
to  the  side  of  the  child's  head,  what  should  be  the 
different  steps  of  the  process  ?  If  the  occiput  be  to- 
wards the  left  ischium,  although  the  left  hand  or  male 
blade  can  be  so  inserted  into  the  pelvis  as  to  embrace 
the  left  side  of  the  head  from  occiput  to  chin,  yet  the 
shank  of  the  instrument  will  necessarily  be  carried  so 
closely  against  the  left  tuber  ischii,  that  it  will  be  im- 


2G0  MEDICINE   AND    SURGERY 

possible  for  the  right  hand  or  female  blade  to  cross  it 
to  lock  properly.  It  therefore  becomes  necessary  in 
most  instances  to  adopt  a  course  differing  from  that 
usually  advised  in  regard  to  manipulation  with  the 
forceps,  viz. :  to  introduce  the  female  first  on  the  pubal 
side  of  the  head,  and  with  the  pubal  curve  of  the  blade 
directed  towards  the  occiput,  then  taking  the  sacral 
edge  of  the  male  blade  in  the  right  hand^  leaving  the 
handle  directed  downwards,  the  tip  of  this  blade  is  to 
be  carried  upon  the  sinciput  first,  then  under  the  left 
parietal  and  temporal  bones  till  it  becomes  placed 
parallel  with  the  clam  of  the  other  blade,  and  the  pivot 
comes  accurately  into  the  notch  of  the  female  blade 
which  had  been  first  introduced. 

In  the  occipito  right-iliac  position,  the  male  blade, 
if  introduced  first,  usually  presents  its  shank  so  strongly 
on  the  median  line  behind  the  pubis,  that  it  is  impos- 
sible to  conduct  the  female  blade  in  the  right  direc- 
tion. It  is  therefore  proper  to  withdraw  the  male 
blade  gradually  and  cause  its  point,  and  part  of  the 
clam  to  rest  upon  the  sinciput,  and  the  left  side  of 
the  vulva  and  vagina,  while  attention  is  paid  to  car- 
rying in  the  female  blade  with  the  right  hand  by  con- 
veying it  to  the  right  side  of  the  head.  When  this  is 
satisfactorily  accomplished,  the  handle  may  also  be 
held  by  an  assistant  while  the  left  hand  blade  is  slided 
round  to  its  proper  position-  on  the  head  under  the 
arch,  and  the  two  branches  brought  into  contact  and 
locked. 

What  forceps  is  probably  best  adapted  to  these 
transverse  or  occipito-ischiatic  positions  ?  The  "  eclec- 
tic" forceps  of  Professor  Hodge. 

If  you  succeed  in  locking  the  forceps  to  your  mind, 
would  you  at  once  turn  the  occiput  to  the  pubic  arch  ? 
It  is  never  proper  to  force  the  occiput  across  the  in- 
clined plane  unless  the  head  has  descended  sufficie«fttly 
low  in  the  pelvis  for  the  forehead  to  get  directly  below 
the  promontory  of  the  sacrum,  after  which  the  opera- 


OF   THE    LYING-IN   CHAMBER.  261 

tion  with  the  instrument  should  be  in  the  direction  of 
the  curve  of  Carus. 

FORCEPS  IN  MENTO-ANTERIOR  CASES  OF  FACE  PRE- 
SENTATION. 

How  shouhl  you  operate  with  the  forceps  in  cases 
of  mento-anterior  positions  of  face  presentations  ? 
Apply  the  blades  as  in  cases  of  occipito-anterior  po- 
sitions, and  as  the  chin  clears  the  anterior  commis- 
sure, draw  a  little  forward  with  the  front  part  of  the 
neck  against  the  under  part  of  the  arch,  then  carry 
the  handles  rapidly  over  towards  the  abdomen  of  the 
mother,  with  a  view  to  move  the  trachelo-bregmatic 
and  the  trachelo-occipital  diameters,  like  radii,  be- 
tween the  arch  of  the  pubes,  the  sacrum,  coccyx,  and 
the  perinaeum. 

FORCEPS  IN  BREECH  PRESENTATION. 

What  other  presentations  of  the  fetus  may  require 
the  application  of  the  forceps  for  the  delivery  of  the 
head?  Presentations  of  the  pelvic  extremity,  in 
which  after  the  delivery  of  the  above,  the  head  is 
retained. 

How  are  you  to  dispose  of  the  body  of  the  child  in 
such  cases?  In  case  the  occiput  is  anterior  the  body 
is  to  be  carefully  lifted  up  over  the  abdomen  of  the 
mother  and  the  forceps  are  to  be  introduced  beloAv  ; 
while  in  posterior  positions  of  the  occiput,  the  body  is 
to  be  carried  toward  the  sacrum  of  the  mother,  and 
the  forceps  are  to  be  introduced  above  the  body  of  the 
child. 

Suppose  the  chin  has  departed  from  the  axis  of  the 
pelvis,  can  you  introduce  and  apply  the  forceps  with 
benefit  ?  They  would  be  ineffectual  in  deUvering  the 
child,  and  subject  the  woman  to  much  risk  of  injury. 

Can  you  hope  to  deliver  the  head  from  the  superior 
straits  after  the  body  has  been  delivered  ?  Scarcely 
ever  easily  nor  often  safely. 

What  accident  is  liable  to  occur  in  cases  of  pelvic 


262  MEDICINE    AND    SURGERY 

presentation  with  the  body  delivered  but  the  head  re- 
tained, if  you  use  great  manual  traction  effort  ?  Se- 
parating the  body  from  the  head. 

Suppose  you  meet  with  a  case  in  which  the  head  is 
retained  after  the  body  has  been  pulled  off,  what  should 
you  do  ?  First  try  to  get  the  head  in  a  proper  posi- 
tion, then  apply  the  forceps. 

But  suppose  you  cannot  get  it  into  the  proper  rela- 
tion with  the  pelvis  for  the  safe  application  of  the 
forceps,  what  means  are  you  to  employ  ?  Hooks, 
vectis,  &c.,  so  applied  to  the  head  as  to  get  it  in  such 
position  that  the  forceps  can  be  applied,  or  that  you 
can  introduce  such  instruments  as  to  enable  you  to 
diminish  its  capacity,  and  afterwards  extract  it. 

DR.  HODGE'S  MODIFICATION  OF  FORCEPS. 

What  is  Dr.  Hodge's  description  and  illustration 
of  his  valuable  modification  of  the  obstetric  forceps  ? 
He  says :  The  great  object  of  the  forceps  is  to  ex- 
tract the  head  of  the  foetus  from  the  mother's  organs 
in  suitable  cases,  without  injury  to  the  mother  or 
child.  It  is  notorious  that  injury  to  one  or  both  par- 
ties frequently  results,  exciting  a  too  well-founded 
dread  of  this  instrument  in  the  minds  of  females  and 
even  of  physicians.  Many  causes  contribute  to  this 
unfortunate  result.  No  doubt  much  depends  on  the 
size,  weight,  and  especially  on  the  form  of  the  instru- 
ment employed,  a  fact  confirmed  by  the  almost  innu- 
merable varieties  which  have  been  suggested.  The 
instrument,  as  heretofore  used,  is  evidently  imperfect ; 
and  the  one  now  suggested,  is  presented  under  the 
impression  that,  while  it  maintains  all  the  excellencies, 
of  the  former  varieties,  the  injurious  influences  are 
partly,  if  not  wholly,  avoided.  It  is  a  modification 
of  the  long  French  forceps,  but  may  be  well  termed 
an  eclectic  forceps,  as  combining  as  much  as  possible 
the  peculiar  excellencies  of  the  English,  German,  and 
French  varieties. 

The  advantages  of  the  French  or  long  forceps  are, 


OF   THE    LYING-IX    CHAMBER.  263 

I  think,  many  and  decided,  as  1st.  by  them,  any  ope- 
ration pertaining  to  this  instrument,  can  be  performed. 
There  is  no  necessity  to  vary  the  form,  structure,  or 
size  of  the  instrument,  whatever  may  be  the  presenta- 
tion of  the  head,  its  position  or  location. 

2d.  By  them,  sufficient  power  can  be  applied  in 
cases  of  necessity,  which  cannot  be  done  by  the  short 
forceps.     Their  leverage  is  gr*eater. 

3d.  The  narrowness  of  the  blades  which,  without 
detracting  from  the  utility  of  this  instrument,  will 
allow  of  their  application  to  the  sides  of  the  head,  even 
in  oblique  and  transverse  positions.  Many  of  the 
modern  English  forceps  are  too  broad  to  allow  the 
proper  manipulation  of  the  instrument  in  the  cavity 
of  the  pelvis.  They  cannot  be  introduced  through  the 
vulva  without  pain,  especially  in  first  labors.  The  French 
forceps  can  very  generally  be  applied  without  pain. 

4th.  It  may  be  added  as  another  advantage,  that 
as  habit,  in  the  use  of  an  instrument,  is  all  important, 
the  practitioner  will  sooner  become  accustomed  to  a 
forceps  which  he  can  employ  on  all  occasions  than 
when  he  is  obliged  to  vary  it  continually ;  especially 
when  it  is  remembered  that  among  the  strong  and 
well  formed  females  of  America,  cases  for  the  forceps 
are  not  very  numerous,  in  the  circle  of  any  practitioner. 

The  disadvantages,  which  experience  has  taught 
me  arise  from  the  French  forceps,  are — 

1st.  Its  unnecessary  weight. 

2d.  The  pelvic  curve,  in  tlie  variety  most  in  use  in 
this  country,  is  not  sufficiently  great.  Hence,  when 
the  head  is  high  in  the  pelvis,  the  perin^eum  will  be 
too  much  pressed  upon,  or  else  the  blades  will  not  be  ap- 
plied in  the  direction  of  the  occipito-mental  or  oblique 
diameter. 

3d.  The  divergence  of  the  blades  commencing  at 
the  joint,  must  necessarily  distend  to  the  vulva  (espe- 
cially its  posterior  margin)  prematurely,  and  when  the 
head  is  high  up,  gives  pain,  and  endangers  the  lacera- 
tion of  the  perinneum. 


264  MEDICINE    AND    SURGERY 

4th.  The  small  size  and  kite-like  shape  of  the 
fenestra  prevents  any  portion  of  the  cranium,  even 
of  the  parietal  protuberances,  projecting  into  their 
openings :  hence  the  hold  on  the  head  is  less  firm, 
and  space  is  occupied  by  the  blades,  the  thickness  of 
which  is  added  to  the  transverse  diameter  of  the 
head. 

5th.  The  flatness  of  the  internal  or  cephalic  sur- 
faces of  the  blades — so  that  the  margin  of  the  fenestra 
often  measuring  three-eighths  of  an  inch  is  much 
thicker  than  the  external  edge  of  the  blade,  increases 
the  space  occupied  by  the  instrument.  Hence,  in 
cases  of  difficulty,  where  compression  is  employed, 
contusion  or  even  wounding  of  the  scalp  results. 

The  mode  of  junction  of  the  French  forceps  is 
decidedly  inconvenient,  when  compared  with  the  Eng- 
lish, and  especially  with  the  German  mode. 

These  disadvantages  I  have  endeavored  to  obviate 
without  diminishing  or  circumscribing  the  utility  of 
this  most  valuable  instrument,  to  which  the  profession 
and  the  public  are  so  much  indebted.  My  experience 
encourages  the  hope,  that  the  attempt  has  been  in  a 
very  great  degree  successful,  so  that  even  in  inexpe- 
rienced hands,  the  dangers  of  the  forceps  have  been 
materially  lessened. 

1st.  The  weight  of  the  instrument  has  been  di- 
minished from  twenty  ounces  avoirdupois,  to  seventeen 
ounces. 

2d.  The  pelvic  curve  has  been  slightly  increased, 
so  that  the  peringeum  may  not  be  dangerously  pressed 
upon,  when  the  blades  are  in  the  axis  of  the  superior 
strait.  To  counteract  any  loss  of  power  which  may 
ensue  from  the  increased  curvature,  there  is  an  angu- 
lar bend  in  the  handles,  in  an  opposite  direction,  that 
the  direct  line  of  traction  may  be  preserved,  a  sugges- 
tion of  our  skilful  and  experienced  instrument- maker, 
Mr.  Rorer. 

3d.  The  shanks,  or  commencement  of  the  blades, 
are  nearly  parallel,  diverging  no  more  than  is  abso- 


OF  THE    LYING-IN   CHAMBER.  265 

lutely  necessary,  until  they  approximate  the  head  of 
the  chihi,  when  a  more  rapid  curvature  than  in  the 
Levret  forceps  occurs. 

4th.  The  proper  blades  of  the  instrument,  from 
the  shanks  to  the  extremities,  are  nearly  of  the  same 
breadth  throughout,  being  equal  to  that  of  the  extre- 
mity of  the  French  forceps. 

The  advantages  are  a  more  secure  hold  of  the 
head,  and  especially  allowing  larger  fenestras,  so  that 
the  parietal  protuberances  may  project  into  the  open- 
ings and  no  space  be  occupied  by  the  blades,  when 
properly  applied. 

6th.  The  cephalic  surface  of  the  blade  is  con- 
cave, so  as  to  be  adapted  to  the  convexity  of  the 
head,  as  suggested  by  Dr.  Davis,  in  his  improved 
forceps,  hence  no  edges  touch  the  scalp,  and  there  is 
no  wounding  of  the  tissues,  even  when  great  compres- 
sion is  made. 

7th.  The  very  ingenious  and  scientific  mode  of 
locking  the  blades,  as  in  the  German  or  Sieboid's  for- 
ceps, by  means  of  a  conical  pivot,  and  the  correspond- 
ing oblique  conical  opening  for  its  reception  is  adopted, 
by  which  all  the  facilities  of  the  English  junction  are 
enjoyed,  and  the  security  and  firmness  of  the  French 
joints  are  maintained. 

The  eclectic  forceps  weigh  one  pound  and  one 
ounce,  being  nine  ounces  lighter  than  the  French  for- 
ceps, as  usually  manufactured  by  Rorer,  of  Philadel- 
phia, and  eleven  ounces  lighter  than  a  specimen  of  Du- 
bois' forceps  in  my  possession,  made  in  Paris.  The 
whole  length  of  the  instrument,  (see  fig.  99)  in  a  di- 
rect line  from  h  to  c  is  16  inches ;  from  the  joint  a, 
to  the  extremity  b,  the  length  of  the  handles,  is  6.8 ; 
from  a  to  d,  the  parallel  shanks  is  3.5 ;  from  d  to  c, 
the  proper  blades  in  a  direct  Hne,  is  6  inches ;  from 
c,  c,  the  extremities,  to  e,  /,  /,  the  greatest  breadth, 
3.7  inches.  The  separation  between  the  points  c,  c, 
when  the  handles  are  in  contact  is  .5  of  an  inch ; 
from   e  to  /,   the    greatest    breadth  when   the    ban- 


266 


MEDICINE    AND    SURGERY 


dies  touch,  is  2.5  ;  when  the  separation  at  ef  is 
3.5,  the  points  tftf  are  separated  2  inches;  the  breadth 
of  the  blade  is  1.8,  slightly  tapering  to  1.7  near 
6'c,  the  extremities.  The  breadth  of  the  fenestra  is 
1.1 ;  the  thickness  of  the  blade  is  .2  of  an  inch.  The 
perpendicular  elevation  of  the  points  c  c,  when  the 
instrument  is  on  a  horizontal  surface,  is  3.4  inches, 
which  indicates  the  degree  of  curvature  of  the  blades. 
The  elevation  of  the  handles,  near  the  joint  above  the 
same  horizontal  line,  is  1.3,  (including  the  thickness 
of  the  blades)  which  indicates  the  extent  of  the  angu- 
lar bend  in  the  handles,  (see  fig.  99  and  reference 
letters.) 


Fig.  99. 


Which  forceps  does  Professor  Meigs  prefer  ?  In  his 
valuable  work  on  obstetrics,  he  says  the  most  conve- 


OF   THE    LYING-IN    CIIAMB2R.  267 

nient  instrument  he  has  ever  employed,  and  the  one  he 
commonly  makes  use  of,  is  that  recommended  by  the 
late  Professor  Davis,  of  the  London  University. 

DR.  BOND'S  REMARKS  ON  OBSTETRICAL  FORCEPS. 

What  very  sensible  observations  respecting  the  con- 
struction and  mode  of  use  of  the  forceps  have  been 
made  by  Dr.  Henry  Bond,  of  Philadelphia,  and  com- 
municated by  him  first  to  the  American  Journal  of  the 
Medical  Sciences  in  July,  1850  ?  At  an  early  period 
of  my  professional  life  it  occurred  to  me  that  obstet- 
rical cases  are  sometimes,  although  not  very  frequently, 
met  with  where  the  use  of  the  forceps  is  clearly  indi- 
cated,  but  where  the  instrument  is  found  defective.  I 
refer  to  those  cases  where,  owing  to  the  position  or  the 
form  of  the  fetal  head,  and  its  relation  to  the  pelvis, 
it  is  found  impracticable  to  adapt  the  clams  to  the 
head  so  as  to  lock  the  branches,  or  to  do  so  without 
violent  injury  to  the  mother  or  child.  There  is  pro- 
bably no  obstetrician  of  large  experience  who  could 
not  furnish  ample  illustrations  of  this  opinion,  if  he 
would  give  a  full  and  faithful  detail  of  his  observations. 

Systematic  writers  tell  us  that  "  we  must  feel  the 
ear,"  or  otherwise  determine  the  precise  situation  of 
the  head,  and  then  the  blades  "  must  be  placed  exactly 
upon  the  parallel  sides  of  the  head,  so  that  they  may 
lock — if  the  handles  do  not  readily  join  upon  the  in- 
troduction of  the  second  blade — then  we  must,  by  ju- 
dicious management  of  the  one  in  fault,  make  it  join 
its  fellow."  [This  term  parallel^  as  employed  by  some 
obstetrical  writers,  is  not  used  correctly.  There  are 
no  parallel  sides  of  the  head,  but  there  are  symmetrical 
sides  or  portions,  using  this  term  in  its  geometrical  ac- 
ceptation. The  term  opposite  will  not  express  their 
idea  in  this  case,  because  the  frons  and  occiput  are  op- 
posite, but  they  are  neither  parallel  nor  symmetrical. 
The  terms  similar  and  correspondent  may  express  the 
idea,  but  their  import  is  more  vague — less  precise  and 


268  MEDICINE   AND    SUKGERY 

technical  than  symmetrical.]  We  are  directed  to 
withdraw  the  blade  in  fault  and  introduce  it  again,  as 
if  that  would  certainly  accomplish  that  exact  adapta- 
tion. When  the  head  is  above  the  brim  of  the  pelvis, 
where  the  use  of  the  forceps  is  sometimes  clearly  indi- 
cated and  urgently  demanded,  it  is  an  empty  pretence 
that  we  can  always  determine  the  exact  position  of  the 
head,  and  not  less  so,  that  "judicious  management" 
will  always  enable  us  to  adapt  the  blades  exactly  to 
symmetrical  portions  of  the  head  so  as  to  lock  readily. 
Dr.  Blundell  says,  "they  (the  long  forceps  in  such 
cases)  are  more  generally  laid  over  the  forehead  and 
occiput."     See  also  Velpeau,  sect.  1061. 

I  will  here  present,  very  briefly,  a  few  illustrative 
cases.  1.  In  the  early  part  of  my  practice,  I  was 
called  to  a  patient  who  was  attacked  with  very  violent 
puerperal  convulsions.  I  requested  a  friend  to  come 
to  my  aid,  bringing  a  forceps  with  him.  We  made  re- 
peated attempts  to  apply  the  instrument,  and  with  a 
similar  result — we  could  not  lock  the  branches.  We 
then  summoned  to  our  aid  a  gentleman  of  much  expe- 
rience and  repute  as  a  teacher  of  obstetrics.  He  in- 
troduced the  blades,  and  he  found  them  no  nearer  to 
an  apposition,  that  admitted  of  locking,  than  we  had 
done.  But,  as  a  professor  must  not  be  thwarted  in 
the  exercise  of  his  own  art,  and,  moreover,  as  the  case 
was  very  urgent,  with  a  strong  hand  he  made  them  lock, 
and  soon  delivered  the  child ;  but  the  temporal  artery 
was  wounded,  the  cranium  was  fractured,  and  the  child 
was  not  a  long  time  dead. 

2.  In  a  case  where  the  use  of  the  forceps  seemed 
to  be  indicated,  and  where  the  head  was  above  the  up- 
per strait,  I  called  to  my  aid  a  gentleman  of  eminent 
skill  and  great  experience.  We  both  attempted  to 
apply  the  instrument,  and  with  equal  want  of  success. 
We  could  not  adjust  it  so  that  the  branches  would  lock, 
or  that  we  could  obtain  any  command  of  the  head. 
The  vectis  was  also  tried  without  success.     The  case 


OF  THE   LYING-IN   CHAMBER.  269 

•was  very  urgent,  and  we  were  obliged  to  resort  to  em- 
hryulcia.  This  is  the  only  instance  in  which  this 
operation  has  been  resorted  to  in  a  patient  of  mine, 
in  a  practice  of  thirty-three  years.  Owing  to  the  dis- 
proportion between  the  dimensions  of  the  head  and  the 
pelvis,  it  is,  indeed,  problematicalwhether  the  delivery 
could  have  been  accomplished  by  means  of  the  forceps, 
if  it  could  have  been  adapted  to  the  head,  so  as  to 
lock ;  but  it  was  very  desirable  to  try  the  problem. 

3.  A  few  years  ago  I  had  a  case,  where,  in  consul- 
tation with  a  friend,  it  was  deemed  necessary  to  use 
the  forceps.  The  head  was  above  the  upper  strait, 
and  I  found  it  impossible  to  apply  the  instrument  so 
as  to  lock  the  branches.  I  then  made  the  female 
branch  bear  upon  the  pivot  without  locking^  allowing 
the  clams  to  be  adapted  to  the  head  obliquely  in  their 
relation  to  each  other ;  and  using  my  hands  as  a  lock, 
with  much  care  to  prevent  slipping,  I  succeeded  in 
safely  delivering  the  child.  If  I  had  forced  the  branches 
to  lock  in  this  case,  some  violence  must  have  been  in- 
flicted on  the  mother  or  child.  This  case,  apparently 
so  simple  and  devoid  of  striking  incidents,  was  to  me 
a  very  instructive  one. 

4.  A  case  occurred  recently  in  this  city,  as  I  have 
heard,  where,  owing  to  the  difficulty  or  impossibility 
of  properly  adapting  the  forceps,  the  superciliary  ridge 
was  fractured  and  the  eye  destroyed.  A  similar  case 
is  mentioned  in  Dewees'  Midwifery.  These  belong  to 
that  too  numerous  class  of  cases,  the  details  of  which 
are  seldom  allowed  to  escape  the  confines  of  the  darkly 
shaded  nursery. 

Dr.  Blundell  very  justly  observes,  "Unless  the 
blades  be  elastic,  absolute  adaptation  can  (I  conceive) 
never  be  obtained;  for  while  the  form  of  the  instru- 
ment remains  unchanged,  that  of  the  head  itself  va- 
ries. The  lock  should  be  loose,  so  as  to  admit  of  a 
junction  of  the  blades,  although  they  may  not  be 
brought  into  exact  apposition  with  each  other ;  for,  in 
applying  them  to  the  head,  this  adaptation  cannot  al- 
23* 


270  MEDICIN-E   AND    SURGERY 

ways  be  obtained."  For  this  reason,  he  says  that 
Smellie's  lock  (made  loose)  is  decidedly  the  best. 

Dr.  Meigs  says,  "If  we  fail  to  adjust  the  branches 
accurately  in  apposition,  we  either  cannot  make  them 
lock,  or  we  lock  them  in  such  a  way  that  the  edge  of 
the  instrument  contuses,  or  even  cuts  the  part  of  the 
scalp  or  cheek  on  which  it  rests,  leaving  a  scar,  or  ac- 
tually breaking  the  tender  bones  of  the  cranium,  while 
the  other  edge  cuts  the  womb  or  vagina  by  its  free  pro- 
jecting edge.  In  fact,  the  forceps  is  designed  for  the 
sides  of  the  head ;  and  if,  under  the  stress  of  circum- 
stances, we  are  compelled  to  fix  them  in  any  other  po- 
sition, (an  incident  not  very  unfrequent,)  we  shall  al- 
ways feel  reluctant  to  do  so,  and  look  forward  with 
painful  anxiety  to  the  birth,  in  order  to  learn  whether 
we  have  done  the  mischief  we  feared,  but  which  we 
could  not  avoid." 

"  The  difficulty  and  the  danger  in  such  cases  evi- 
dently arise,  to  a  great  extent,  from  the  want  of  an 
accommodating,  rocking  motion  of  the  branches  of  the 
forceps  upon  each  other,  such  as  will  allow  the  de- 
pressed ("  cutting  and  contusing")  edge  to  rise,  and  the 
elevated  edge  to  sink  and  come  in  contact  and  apposi- 
tion with  the  head  ;  that  is,  so  that  the  blades  may  be 
adapted  to  the  head  by  varying  from  their  usual  rela- 
tion to  each  other. 

[See  "  Obetstrics,"  the  science  and  the  art,  for  ex- 
cellent lessons  and  much  information  on  the  use  of  the 
forceps.  I  commend  attention  to  the  author's  em- 
phatic inculcation  of  the  idea,  that  the  forceps  is  the 
child's  instrument,^ 

None  of  the  French  forceps,  or  their  numerous 
modifications,  so  far  as  I  know,  are  intended  to  admit 
of  such  a  motion.  When  locked,  they  are  truly 
locked ;  and  whatever  be  the  form  of  the  head,  or 
whatever  the  parts  of  the  head  to  which  the  instrument 
is  applied,  the  head  must  conform  to  the  forceps  and 
not  the  forceps  to  the  head.  Smellie's  joint  (which 
can  hardly  be  called  a  lock)  will  admit  of  some  motion, 


OP  THE    LYING-IN    CHAMBER.  271 

if  made  loose,  as  recommended  by  Dr.  Blundell ;  but 
this  motion  is  very  limited  and  unregulated.  Dr.  Da- 
vis, of  London,  has  adopted  Smellie's  joint,  (fig.  100)  but 
without  observing  Dr.  Blundell's  precaution  as  to  its 

looseness. 


Fig.  100. 


The  lock  of  Dr.  Siebold's  forceps,  when  the  pivot  is 
partly  unscrewed,  will  admit  of  the  lateral  motion  of 
on^  branch  upon  the  other,  to  a  very  considerable  ex- 
tent. The  branches  of  forceps  are  two  levers  of  the 
first  kind,  the  pivot  being  the  common  fulcrum  of 
each.  It  is  to  be  observed  in  Siebold's  forceps, 
that  the  branches  are  so  much  curved — make  so 
wide  a  sweep — that  the  fulcrum  is  far  removed  from 
the  direct  line  between  the  power  (the  hand)  and  the 
weight  (the  head) ;  and  it  will  be  seen  on  examination 
that  this  circumstance  will  render  their  lateral  or  rock- 
ing motion  nearly  useless,  if  not  dangerous.  Indeed, 
I  should  infer,  from  the  structure  of  the  joint  and  the 
form  of  the  blades,  that  the  use  of  this  motion  was 
never  contemplated  by  the  inventor. 

A  forceps  was  exhibited  to  the  profession  in  this 
city,  several  years  ago,  devised  with  a  view  to  supply 
a  rocking,  accommodating  motion.  It  was  constructed 
with  a  swivel  joint  in  each  shank,  allowing  motion  to 
a  limited  extent.  The  objections  to  it  were,  1st.  That 
this  joint  rendered  the  blade  very  weak,  and  that  it 
would  almost  unavoidably  become  corroded  with  rust. 
2d.  That  the  operator  had  no  control  over  the  motion 
of  it  J  it  would  rock  or  wabble  always,  whereas  the 


272 


MEDICINE   AND    SURGERY 


rocking  motion  is  not  commonly  requisite.  This  un- 
restricted motion,  together  with  the  form  of  the  blades, 
would  render  this  instrument  very  liable  to  slipping  or 
displacement.  I  have  forgotten  the  name  of  the  in- 
ventor, and  I  am  not  aware  that  there  is  a  specimen 
of  the  invention  in  this  city. 

In  the  instrument  (from  the  manufactory  of  Messrs. 
John  Rorer  &  Sons,  of  Philadelphia,  made  of  German 
steel,  and  spring -tempered,)  which  is  illustrated  in  fig. 
101,  I  have  attempted  to  supply  what  has  seemed  to 

Fig.  101. 


me  an  obvious  desideratum,  viz.,  to  give  the  branches 
of  the  forceps  an  accommodating  rocking  motion 
upon  each  other,  the  extent  of  which  can  he  regu- 
lated at  will,  and  which  shall  in  7io  respect  lessen 
the  power  of  the  instrument.  The  mechanism  devised 
to  obtain  this  motion  is  very  simple,  not  liable  to  de- 
rangement, and  it  may  be  adopted  in  the  construction 
of  forceps  of  other  forms  than  that  here  presented  ; 
provided  that  the  pelvic  curvature  of  the  branches 
does  not  take  such  a  wide  sweep,  as  to  throw  the  pivot 
far  out  of  the  direct  line  between  the  handle  and  the 
centre  of  the  fenestrje.  [There  being  some  vagueness 
and  discrepancy  in  the  use  of  the  terms  employ.ed  in 
describing  the  obstetrical  forceps.  T  i^^-e  offer  some  ex- 


OF   THE   LYING-IN  -  CHAMBER.  273 

planatory  remarks.  These  may  be  entirely  super- 
fluous to  many  readers,  but  perhaps  not  so  to  all.  A  for- 
ceps consists  of  two  branches  (brachia)  and  a  pivot  or 
fulcrum  (that  is,  in  such  forceps  as  have  their  branches 
connected  by  a  pivot).  A  branch  consists  of  the  han- 
dle {manubrium)^  which  extends  to  the  joint  (junctura), 
and  of  the  blade  (^cochleare),  which  extends  from  the 
joint  to  the  remote  point.  The  blade  consists  of  the 
clam  {cochlea),  which  is  that  concave  portion  of  it  in- 
tended to  embrace  the  head,  and  the  shank  (femur), 
that  portion  between  the  joint  and  the  clam.  This  di- 
vision of  the  blade  into  shank  and  clam  is  not  recog- 
nized by  Mulder,  but  it  has  become  very  convenient  if 
not  absolutely  necessary.  The  two  parts  of  the  clam, 
on  the  side  of  the  opening  or  fenestra,  are  sometimes 
called  the  limbs  of  the  blade,  viz.,  the  upper  limb,  and 
the  under  or  outer  limb.  The  pivot  consists  of  the 
thumb  piece,  the  screw,  and  the  intermediate  beari7ig 
point  or  fulcrum.  When  the  branches  are  connected 
by  a  pivot,  they  are  usually  designated  as  the  male 
and  the  female  branches ;  that  which  has  the  notch 
for  the  reception  of  the  pivot,  being  the  female,  and 
the  other  the  male  branch.  Dr.  Velpeau  designates 
the  two  branches  as  the  right  and  the  left,  from  the 
position  of  the  handles  as  held  in  the  hand  of  the 
operator.  It  seems  to  me  more  appropriate  to  desig- 
nate them  from  the  position  of  the  blades,  these  being 
the  more  essential  parts  of  the  instrument,  and  the 
attention,  in  an  operation,  being  directed  more  to  the 
position  of  the  blades  than  to  that  of  the  handles. 
Otherwise  the  blades  seem  to  be  playing  at  cross-pur- 
poses— the  right  blade  being  on  the  left,  and  the  left 
on  the  right.  I  am  aware  that  it  may  be  said,  in  sup- 
port of  that  usage,  that  the  branches  are  named  right 
and  left,  in  reference  to  the  pelvis  of  the  patient.  For 
the  same  reason,  when  riding  backwards  in  a  coach,  a 
man's  right  hand  becomes  his  left.  As  one  curve  of 
the  forceps  is  made  in  reference  to  the  form  of  the 
head,  and  the  other  to  that  of  the  pelvis,  it  seems  to 


274 


MEDICINE   AND    SURGERY 


me  more  distinctive  and  suggestive  to  name  them  re- 
spectively the  cranial  and  the  pelvic  curvatures,  than 
the  old  and  the  new  curvatures.  This  was  new  in  the 
time  of  Levret,  but  it  has  ceased  to  be  so ;  and  we  do 
not  derogate  from  the  credit  of  the  inventor  of  that 
important  improvement  by  giving  it  an  expressive 
term.] 

The  instrument  will  be  seen  to  differ,  as  a  whole, 
from  any  now  in  use  ;  although  no  one  of  its  modifica- 
tions, except  the  lock,  has  any  claim  to  novelty.  The 
handles  are  Dr.  Siebold's,  with  unimportant  modifica- 
tions. The  blades  are  a  little  modified,  from  Dr. 
Davis's,  shown  in  fig.  102  on  a  small  scale.    Its  whole 


Fig.  102. 


length  is  about  fifteen  inches,  and  its  weight  about  fif- 
teen ounces.  The  length  of  the  handle  is  six  inches,  and 
that  of  the  blade  nine  inches.  It  might  be  made 
somewhat  shorter  and  lighter  without  impairing  its 
power. 

Of  the  Loch, — In  fig.  103,  the  screw  is  of  about 
double  the  diameter  and  nearly  double  the  length  of 
those   in   other  instruments.     This  addi- 
tional strength  is  necessary,  because  the 
bearing  point  of  the  pivot  is  not    imme- 
diately above  the  blade  in  which  it  is  in- 
serted (as  in    other   instruments),     espe- 
cially when  this  bearing  point  is  elevated 
so  as  to  give  the  blades  a  free  rocking  mo- 
tion.   The  additional  length  is  required  to 
give  the  screw  a  firm  lodgment,  when  it  is  partly  with- 
drawn from  the  blade.  The  thumb-piece  is  made  to  fit  so 


Fig.  103. 


,  OF   THE    LYING-IN    CHAMBER.  275 

close  upon  the  female  blade,  but  without  resting  upon 
it,  and  is  so  thick  and  rounded,  that  there  may  be  no 
risk  of  injury  shodld  it  ever  happen  to  be  brought  in- 
to contact  with  the  patient.  The  screw,  when  well 
made,  will  turn  so  easily  that  the  thumb-piece  may  be 
made  much  less  prominent  than  it  is  here  represented. 
When  the  forceps  is  used,  the  thumb-piece  should  be 
placed  parallel  with  the  blades ;  otherwise  it  may  in- 
terfere with  the  rocking  motion.  Between  the  thumb- 
piece  and  the  screw,  the  pivot  is  of  the  form  of  two 
frusta  of  cones  of  equal  dimensions,  united  together 
at  their  smaller  diameters,  forming  an  obtuse  angle  or 
groove  at  their  junction.  The  base  of  that  cone  joined 
to  the  screw  projects  a  little,  forming  a  shoulder,  in- 
tended to  limit  the  motion  of  the  screw  into  the  blade. 
The  notch  in  the  female  blade,  made  to  receive 
the  pivot,  is  so  deep  that  the  pivot,  in  relation  to 
the  edges  of  the  branch,  is  nearly  in  the  middle ; 
yet  the  width  of  this  branch,  opposite  to  it,  is  swelled 
out,  so  as  to  give  it  adequate  firmness.  The  width 
and  the  form  of  the  sides  of  the  notch  are  accurately 
adapted  to  those  of  the  pivot,  and  the  bottom  of  the 
notch  terminates  in  an  edge,  like  the  knife-edge  of  a 
balance,  which  is  intended  to  rest  in,  and  bear  upon, 
the  angle  or  groove  in  the  pivot.  On  the  under  side 
of  the  male  blade  is  seen  a  protuberance,  finished  so 
as  to  present  no  salient  points.  It  is  a  shield  for  the 
extra  length  of  the  screw.  When  the  pivot  is  screwed 
entirely  down,  the  branches  have  no  more  lateral  or 
rocking  motion  than  those  of  any  other  forceps,  and, 
in  this  condition,  they  will  very  generally  be  used. 
But  by  turning  the  screw,  so  as  to  elevate  the  bear- 
ing point,  more  or  less  freedom  is  given  to  the  rock- 
ing motion,  according  to  its  elevation ;  and  this  mo- 
tion is  effectually  restricted  within  any  desired  limits. 
When,  by  means  of  this  free  motion,  the  operator  has 
been  enabled  to  grasp  the  head,  he  may  sometimes 
change  its  position,  so  that  the  clams  may  be  then 
adapted   to   the   head,  without   the   obliquity  at  firbt 


276  MEDICINE    AND    SURGERY      . 

necessarily  allowed  to  them  liy  the  elevation  of  the 
pivot;  and  then,  if  desirable,  the  pivot  may  be  screwed 
down,  and  the  blades  will  become  as  fixed  as  those  of 
other  forceps. 

Two  objects  seem  to  have  been  kept  more  or  less 
in  view  by  the  various  modelers  of  the  obstetrical 
forceps.  One  of  these  objects  has  been  efficiency, 
having  reference  chiefly  to  the  certainty  of  accom- 
plishing the  delivery.  Of  this  sort  is  the  long  heavy 
French  forceps,  and  to  some  extent  its  several  modi- 
fications. It  is  undoubtedly  a  powerful,  but  danger- 
ous instrument.  The  narrowness  of  the  blades  allows 
them  to  be  introduced  with  comparative  ease  to  the 
operator,  and  then  (with  such  powerful  levers,  as  their 
long  handles)  also  to  be  locked  with  apparent  ease, 
without  being  adapted  to  the  head.  They  must  be 
efficient  in  the  hands  of  a  bold  operator  in  effecting 
*'  a  triumph  of  the  art,"  but,  like  other  victories,  too 
often  attended  with  havoc.  [See  Blundell's  "  Obste- 
tric Medicine,"  part  ii.,  chap,  viii.,  sec.  3,  last  para- 
graph.] The  other  of  these  objects  has  been  safety, 
especially  for  the  child.  Dr.  Davis,  of  London, 
seems  to  me  to  have  had  this  object  especially  in 
view  in  modeling  his  forceps,  and  to  have  been  so 
engrossed  with  it  that  he  has  not  had  a  due  regard 
to  efficiency.  Such  blades  as  his,  in  awkward,  inex- 
perienced hands,  and,  indeed,  in  any  hands,  are  pro- 
bably less  easily  introduced  so  as  to  be  locked  than 
the  French  forceps  ;  because,  for  the  purpose  of  lock- 
ing, they  require  a  more  exact  adaptation  ;  but  when 
applied  they  are  much  safer — there  will  be  much 
less  p^^obability  of  injuring  the  child.  The  French 
forceps  have  received  several  successive  modifications 
in  this  country,  which  add  much  to  their  safety  and 
convenience.  Indeed,  some  accoucheurs  extol  some 
of  these  modifications  as  the  ne  plus  ultra  and  al- 
most the  sine  qua  non  of  obstetrical  instrumentality. 

It  will  be  seen  that  the  blades  of  those  here 
presented    (fig.    104,)     resemble    nearly    those    of 


OF   THE    LYING-IN    CHAMBER.  211 

Dr.  Davis.       The   shanks    are    considerably  longer ; 
the  clams  are  not  ^uite  so  long ;  the  radius  of  their 


Fig.  104. 


pelvic  curvature  is  a  little  less,  especially  that  of 
the  outer  limbs,  so  that  it  will  be  less  liable  to  be 
obstructed  by  the  promontory  of  the  sacrum,  in  pass- 
ing the  instrument  above  the  superior  strait.  The 
fenestrns  are  wider  in  theii"  middle  and  posterior  pait 
than  those  in  most  other  forceps  now  in  use.  When 
the  pivot  is  elevated,  so  as  to  allow  the  blades  their 
rocking  motion,  this  width  becomes  especially  requi- 
site in  order  to  secure  a  firm  hold  on  the  head,  and 
to  avoid  the  risk  of  their  slipping  sideways.  The 
space  between  the  blades  is  such,  that,  when  applied 
to  the  head,  the  handles  shall  not  be  at  a  distance 
from  each  other,  awkward  and  inconvenient  to  the 
operator.  From  the  pivot,  the  upper  line  of  the 
shank  continues  forward,  without  any  elevation  or  de- 
pression to  the  beginning  of  the  pelvic  curvature  ; 
and  the  form  and  the  relation  of  the  shank  to  the 
clam  are  intended  to  be  such  as  to  interfere  the  least 
with  the  perinaium. 

While  a  form  has  been  selected,  which,  it  is  be- 
lieved, will  admit  of  application  easy  and  safe  for  the 
mother  and  child,  and  grasp  the  head  above  the  su- 

Fig.  105. 


278  MEDICINE    AND    SURGERY 

perior  strait,  it  will  be  seen  (fig.  105,)  that  the  pivot 
is  in  a  direct  line  between  the  handles  and  the  centre 
of  the  fenestrge.  This  is  a  point  of  importance  in 
those  cases  where  the  rocking  motion  of  the  blade 
may  be  required,  as  it  will  cause  each  limb  of  the 
clams  to  press  with  nearly  equal  force,  thus  avoiding 
undue  pressure  upon  any  one  part  of  the  head,  and 
the  liability  to  slipping  or  displacement. 

The  handles  are  made  partly  of  ebony,  and  they 
resemble  those  of  Siebold,  although  considerably 
lighter.  The  precise  model,  of  those  represented  in 
the  illustration,  is  not  important ;  for  it  may  be 
varied  to  suit  the  grip  or  the  taste  of  diiferent  ope- 
rators. The  objects  aimed  at  in  their  construction 
should  be,  first,  such  a  length,  compared  with  that  of 
the  whole  instrument,  as  to  give  a  sufficiently  firm 
hold  and  pressure  upon  the  head,  without  inflicting  a 
dangerous  compression ;  and,  secondly,  such  a  form 
as  to  allow  them  to  be  easily  grasped  in  the  hand  of 
the  operator,  with  the  full  assurance  that  he  has  the 
best  command  of  the  instrument,  without  the  danger 
of  slipping,  and  without  the  necessity  of  a  napkin 
envelope.  These  qualities  do  not  belong  to  the  long 
polished  steel  handles,  which  are  heavy,  upon  which 
the  wet,  oiled  hand  of  the  operator  must  slip,  and  which 
even  when  encumbered  with  a  napkin,  must  convey  an 
uncomfortable  sensation  of  misgiving.  Ask  the  litho- 
tomist  or  amputator  how  he  would  like  to  have  his  in- 
struments finished  with  such  handles  that  he  would  be 
obliged  to  grasp  them  wrapped  in  a  napkin  ?  One 
prominent  objection,  if  not  the  chief  one,  to  Dr. 
Davis's  forceps,  is  the  shortness  of  the  handles 
and  their  uncomfortable  grip,  except  in  a  hand  in- 
conveniently large  for  an  accoucheur.  They  cannot, 
however,  slip  in  the  hand,  like  those  of  polished 
steel. 

The  attempts  to  combine  several  other  instru- 
ments in  the  handles  of  the  forceps,  I  regard  as,  ge- 
nerally, worse  than  useless.     With  the  long  polished 


OF   THE    LYING-IN    CHAMBER.  279 

steel  handle  may  be  combined  an  efficient  blunt  hook. 
Bat  with  such  a  heavy,  mis-shapen  handle,  the  ope- 
rator would  be  much  more  liable  to  injure  the  mother 
or  child  than  with  a  well-constructed  blunt  hook.  I 
refrain  from  any  criticism  upon  such  useless  perfora- 
tors and  dangerous  crotchets  as  I  have  seen  com- 
bined with  forceps.  It  is  sufficient  for  an  instrument, 
so  important  as  the  forceps,  that  it  is  exactly  fitted  for 
the  performance  of  its  appropriate  uses.  In  skilful 
hands  it  will  preclude  the  demand  for  the  perforator 
or  the  crotchet,  except  in  very  rare  cases ;  and  in 
these  terrible  cases,  truly  of  life  and  death,  the  ope- 
rator ought  not  to  be  satisfied  with  instruments  which 
are  but  ill-contrived  suecedanea. 

I  am  aware  that  the  first  impression  of  some  per- 
sons, upon  looking  at  the  illustrations,  will  be,  that 
the  instrument  is  too  strait,  that  the  pelvic  curvature 
ought  to  be  continued  into  the  shanks.  If  the  whole 
operation,  or  the  most  difficult  and  important  part  of 
it,  consisted  in  passing  the  blades  above  the  superior 
strait,  narrow  blades,  with  a  curve  of  a  wider  sweep, 
like  those  of  Professor  Siebold,  slipping  in  probably 
with  rather  more  facility,  would  be  preferable.  But 
as  those  here  represented  can  be  passed  above  the 
superior  strait  with  facility,  it  seems  to  me  that  what 
I  have  already  said  upon  the  importance,  in  many 
cases,  of  having  the  pivot  in  nearly  a  direct  line  be- 
tween the  handles  and  the  fenestra,  furnishes  a  valid 
reason  for  adopting  a  model  not  differing  essentially 
from  that  here  presented. 

Others  may  object,  that  unskilful  and  incautious 
persons  will  be  tempted  to  carelessness  in  applying 
such  a  forceps,  and  to  avail  themselves  of  the  free 
motion  of  its  lock  unnecessarily.  Professors  of  ob- 
stetrics, if  they  deign  to  notice  it,  ought  to  give  their 
pupils  the  proper  directions  and  precautions  in  the 
use  of  this  instrument,  as  they  do  in  that  of  others. 
Some  persons  are,  indeed,  so  unhandy  in  the  use  of 
any  instrument   or  tool,  that  all  the  professors  in  the 


280  MEDICINE   AND    SURGEKY 

land  cannot  give  them  such  tact  and  dexterity,  that 
they  ought  to  be  allowed  to  approach  the  puerperal 
bed.  Should  this  instrument  happen  to  fall  into  such 
hands,  the  danger  to  either  mother  or  child  would 
probably  be  much  less  than  from  the  use  of  power- 
ful, unaccommodating  forceps,  misapplied  by  such 
hands. 

Others  may  object  that  it  is  an  innovation,  a  gim- 
crack  novelty — for  they  are  the  conservatives^  scrupu- 
lously maintaining  the  ancient  landmarks.  It  differs 
from  the  one  extolled  by  their  venerated  preceptor, 
the  one  to  which  they  have  been  accustomed,  and  in 
the  use  of  which  experience  has  given  them  expert- 
ness.  Long  companionship  produces  partiality,  and 
perhaps  some  little  modification  of  their  own  may 
have  given  them  the  feelings  of  paternity.  It  has 
answered  their  purpose,  for  with  it  they  have  accom- 
plished delivery  safely ;  and  if,  in  some  instances, 
they  have  wounded  the  integuments  or  fractured  the 
cranium ;  or  if  they  have  been  compelled  to  resort 
to  the  perforator,  in  cases  where  the  forceps  was  in- 
dicated, they  will  console  themselves  with  the  reflec- 
tion that  it  was  an  inevitable  destiny — a  fault  of 
nature,  and  not  a  defect  of  art. 

In  conclusion,  I  must  observe  that  I  am  by  no 
means  pertinacious  for  the  precise  model  of  the  in- 
strument presented  in  the  illustration  ;  for  it  is  not 
improbable  that  experience  may  suggest  modifications 
of  it,  which  will  improve  its  adaptability,  and  yet 
retain  its  essential  principles.  All  I  ask  is,  a  care- 
ful and  candid  examination  of  those  principles. 

LABOR  COMPLICATED  BY  DISTORTION  OF  THE  PELVIS. 

What  diseases  often  result  in  distortion  of  the  pel- 
vis ?     Rachitis,  or  mollitis  osseum. 

What  varieties  of  form  do  pelves  assume  from  rickets 
or  softening  of  the  bones  ?  Nearly  every  conceivable 
variety,  as  may  be  seen  by  diagrams  taken  from  ac- 
tual specimens  collected  both  in  Europe  and  this  coun- 


OF    THE    LYING-IN    CHAMBER.^  281 

try.    Thus,  while  fig.  106  gives  a  faithful  representation 
Fig.  106. 


of  well  arranged  iliac  fossae  and  a  superior  strait  of 
standard  dimensions ;  and  fig.  107  exhibits  the  normal 

Fig.  107. 


proportions  of  the  inferior  strait  of  a  well-formed 
pelvis,  the  departures  from  this  standard  are  very  va- 
riable, partly  in  consequence  of  the  manner  in  which 
the  rickets  or  mollities  have  affected  the  different  por- 
tions of  bone  constituting  the  pelvic  canal,  and  partly 
also  in  consequence  of  the  position  in  which  the  pa- 
tient had  been  during  the  confinement  necessary  in 
24* 


282  .      MEDICINE   AND    SURGERY 

some  cases,  Avhile  the  bones  were  in  a  merely  gelati- 
nous state,  it  may  be  observed,  that  the  antero -poste- 
rior diameter  of  the  superior  strait  is  sometimes  elon- 
gated, so  as  to  give  the  inlet  an  oblong  appearance  as 
in  fig.  108  ;  while  on  the  contrary,  the  sacro-pubal  dia- 

Fig.  108. 


meter  is  so  much  abbreviated  as  to  give  the  entrance 
to  the  canal  the  resemblance  of  the  numeral  8,  placed 
transversely,  as  shown  in  fig.  109,  in  which,  as  will  be 


easily  seen,  the  antero-posterior  diameter,  though 
strictly  on  the  median  line  of  the  body,  is  very  much 
shortened,  while  the  ilia  are  so  widely  separated  as  to 
make  the  transverse  mensuration  abnormally  long, 
the  oblique  diameters  measuring  nearly  or  quite  the 
usual  length.     Besides  this  a  less   regular   form    is 


OF   THE    LYING-IN    CHAMBER.  283 

shown  in  fig.    110,  while  a  considerable  lateral  dis- 
Fig.  110. 


tortion   is   exhibited  in  fig.  Ill,  and  a  still  greater 
Fig.  111. 


one  is  represented  in  fig.  112,  in  which  it  may  be  ob- 
served, that  the  antero-posterior  diameter,  starting 
from  the  middle  of  the  promontory,  will  fall  not  on 
the  pubes  but  over  the  left  acetabulum;  and  that 
while  the  right  oblique  diameter  is  nearly  or  quite 
normal,  the   left    one   is   greatly  abridged.     At  the 


284  MEDICINE    AND    SURGERY 

Fig.  112. 


same  time  can  be  seen  in  fig.  113,  that  variety  of 
Fig.  113. 


distortion,  dependent  apparently  upon  equal  soften- 
ing of  the  pubic  bones,  and  their  approximation  by 
the  resistance  made  by  the  femora  to  the  superin- 
cumbent "weight  of  the  trunk. 


OF   THE    LYING-IN   CHAMBER.  285 

Why  do  the  distortions  usually  take  place  in  the 
direction  of  the  sacro-pubal  diameter  ?  From  the  fact 
that  the  pressure  is  made  in  that  direction  by  the  su- 
perincumbent weight  of  the  spine  or  body. 

What  is  the  smallest  size  in  diameter  through  which 
a  living  child  can  be  delivered  if  arrived  at  term  ? 
Three  inches. 

If  less  than  this,  is  it  proper  for  the  accoucheur  to 
wait  for  the  effects  of  the  natural  powers  ?  It  is  not, 
because  all  the  efforts  of  the  womb  and  the  woman 
would  be  ineffectual. 

MODE  OF  MEASURING  THE  DISTORTIONS. 

What  methods  have  been  proposed  for  ascertaining 
deformity  of  the  pelvis  ?  Very  many  modes  of  ascer- 
taining the  mensuration  of  the  pelvis,  by  instruments 
intended  to  be  applied  externally  or  internally,  or 
both.  Hence  we  have  the  pelvimeter  of  Baudelocque, 
of  Coutouly,  of  Stein,  of  Stark,  of  Simeon,  of  Boivin, 
and  others,  for  ascertaining  by  various  modes  of  appli- 
cation, the  dimensions  of  certain  portions  of  the  pelvis. 

What  is  the  pelvimeter,  or  calliper  of  Baude- 
locque ?  His  compas  d'^paisseur,  or  calliper  is  con- 
trived with  a  bulb  at  the  upper  ends  of  the  instrument 
with  a  graduated  scale  near  the  middle  of  each  limb, 
and  is  so  constructed,  that  when  the  limbs  are  sepa- 
rated from  each  other,  the  scale  will  indicate  the  de- 
gree of  the  expansion,  and  consequently  indicate  the 
dimension  of  the  body  embraced  within  the  points 
when  applied  to  the  mensuration  of  it. 

How  is  the  instrument  to  be  used  ?  One  of  the 
bulbs  is  to  be  brought  as  nearly  as  possible  in  contact 
with  the  symphysis  pubes,  and  the  other  to  the  tip  of 
the  first  spinous  process;  observe  the  intervening  space 
upon  the  scale,  and  you  thus  obtain  the  external 
measurement  of  the  sacro-pubal  diameter  of  the  exte- 
rior of  the  pelvis.  By  deducting  two  and  a  half  inches 
for  the  usual  thickness  of  the  base  of  the  sacrum,  and 
half  an    inch    for    the    thickness  of  the    pubes,    the 


286 


MEDICINE   AND    SURGERY 


remainder  will  indicate  nearly  or  quite  the  sacro-pubal 
interspace,  (see  fig.  114.) 

Fig.  114. 


Fig.  115. 


What  in  practice  has  been  found  more  convenient 
and  reliable  than  any  of  the  various  instrumental 
pelvimeters  ?  The  index  finger 
of  the  accoucheur,  carried  with 
its  radial  edge  against  the  curve 
of  the  pelvic  arch  towards  the 
promontory  of  the  sacrum,  as 
shown  in  fig.  115. 

If  he  cannot  reach  the  sacro- 
vertebral  angle  by  this  means 
short  of  carrying  the  entire  hand 
within  the  vulva,  need  he  en- 
tertain any  apprehension  of  want 
of  space  for  the  head  to  pass 
in  this  direction  ?  Under  such 
circumstances  he  will  have  no- 
thing to  fear  in  this  respect, 
but   if    the   point    of  his   finger 


OF    THE    LYING -IN    CHAMBER.  287 

should  reach  the  promontory,  and  the  nail  of  the  in- 
dex finger  of  the  other  hand  be  applied  upon  it  at  the 
point  of  contact  with  the  pubic  arch,  and  the  finger 
be  withdrawn,  the  measurement  of  the  inter-space 
can  be  sufficiently  accurately  ascertained. 

Is  it  expedient  to  carry  the  hand  into  the  vulva 
unless  the  woman  be  in  labor,  and  indeed  have  at  the 
time  a  pain  ?  It  must  rarely  if  ever  happen  that  there 
will  be  occasion  for  doing  more  than  to  introduce  the 
index  to  the  commissure,  or  perhaps  the  index  asso- 
ciated with  the  middle  finger  may  be  carried  as  far  as 
the  commissure  between  it  and  the  next,  which  should 
be  kept  in  a  state  of  flexion  in  all  cases  of  examina- 
tion unless  when  the  patient  is  in  labor. 

What  are  Dr.  Meigs'  remarks  on  this  digital  means 
of  measurement  ?  He  says,  as  a  general  rule,  the  in- 
dicator finger  of  the  accoucheur  w^ill  scarcely  be  found 
Capable  of  extending  further  than  three  and  a  quarter 
or  three  and  a  half  inches  beyond  the  crown  of  the 
pubal  arch.  It  is  true,  that  by  the  introduction  of 
half  the  hand,  the  palp  of  the  indicator  finger  can 
be  made  to  explore  a  region  of  four  and  a  half  inches 
distant  from  the  crown  of  the  arch  ;  but,  as  the  intro- 
duction of  half  the  hand  in  the  woman  not  in  labor, 
or  aff"ected  only  with  the  earliest  signs  of  labor,  is  so 
painful  as  to  excite  the  greatest  repugnance  and  re- 
sistance on  the  part  of  the  patient,  the  vaginal  taxis 
is  generally  preferred  with  the  indicator  alone. 

MODE  OF  DELIVERY  IN  CASES   OF  PELVIC  DISTORTION. 

What  resources  has  the  practitioner  in  such  cases 
of  distortion  of  the  pelvis  as  do  not  allow  the  child 
of  full  size  to  pass  through  it  ?  Premature  delivery, 
artificially  induced,  or  craniotomy,  or  the  cesarean 
section,  i.  e.,  gastro-hysterotoray. 

What  is  afforded  by  the  perforation  of  the  cranium, 
and  the  breaking  up  of  the  pulpy  mass  ?  An  oppor- 
tunity for  the  vault  *of  the  cranium  to  collapse,  and 
pass  down  more  readily. 


288 


MEDICINE   AND    SURGERY 


What  are  tlie  diameters  of  the  base  of  the  skull 
after  the  vault  has  been  removed  ?  The  face  measures 
one  and  a  half  inches ;  two  inches  with  the  lower  jaw. 
The  transverse  diameter  of  the  base  of  the  cranium  is 
two  and  a  half  inches. 

What  is  the  operation  of  diminishing  the  size  of 
the  child's  head  called?  Craniotomy,  cephalotomy, 
and  embryotomy. 

CRANIOTOMY. 
What  instruments  are  used  for  the  purpose  of  open- 
ing the  head  ?     A  simple  trocar,  which  is  capable  of 
making  an  orifice  of  capacity  equal  only  to  the  circum- 
ference of  its  cutting  surface,  as   shown  in    fig.  116 ; 

Fig.  116. 


a  scissors,  as  devised  by  Smellie  with  edges  about 
one  inch  long,  cutting  outwardly,  which,  when  the  two 
blades  are  brought  together  resemble  a  trochar  cleft  in 
the  direction  of  its  long  axis  ;  a  scissors  with  double 
cutting  edges,  and  slightly  curved  on  one  of  its  lat- 
eral surfaces,  as  contrived  by  Dr.  D.  D.  Davis;  a 
scissors  curved  on  one  of  its  edges,  with  one  point 
longer  than  the  other,  as  modified  by  Dr.  Hodge,  and 
specimen  given  in 

Fig.  117. 


What  advantage   are  the  scissors  of  Smellie  sup- 
posed to  afford  over  the  simple  trocar,  for  perforating 


OP   THE   LYING-IN    CHAMBER.  289 

the  cranium  ?  Their  capahility  furnished  the  oper- 
ator in  making  a  larger  opening  by  sepai^ting  the 
blades  of  the  scissors. 

Is  it  always  easy  to  open  the  blades  of  such  scissors 
by  a  single  hand  ?  The  scalp,  inter-cranial  mem- 
branes, and  the  margins  of  the  "bones,  sometimes 
oppose  the  expansion  of  the  blades  of  these  scissors 
by  the  extensor  muscles  of  one  hand  only,  which  there- 
fore requires  the  combined  force  of  two  hands  and 
abducting  muscles  of  both  arms  to  accomplish  this 
object.  The  scissors  devised  by  Dr.  Hodge  are  an 
exception  to  this  objection,  because  after  perforating 
they  cut  in  the  opposite  direction. 

What  are  some  of  the  contrivances  which  have  been 
proposed  to  obviate  this  difficulty  in  attempting  to 
increase  the  opening  from  a  point  to  a  long  slit  ? 
There  have  been  several  modifications  of  the  original 
trocar,  or  perce-crane,  divided  like  Smellie's  scissors, 
but  so  constructed  as  to  be  opened  by  the  flexor  mus- 
cles of  the  hand,  one  by  a  German  accoucheur,  oru? 
by  Dr.  J.  L.  Ludlow,  of  Philadelphia,  and  one  by 
Mr.  Holmes,  of  England.  Ludlow's  instrument  is 
shown  in 

Fig.  118. 


^^ 


What  is  the  general  description  of  Holmes'  perfo- 
rator ?  When  the  two  handles  are  most  widely 
separated,  the  two  sections  of  the  cutting  blades 
are    in    contact,    and   represent   a  v-o-   nq 

partially  cleft  perce-crane,  as  shown 
by  a  section  of  the  instrument 
in  fig.  119.  In  proportion  as 
the  handles  are  made  to  approach 
each  other,  (as  shown  in  fig.  120,)  these  blades   are 


290  MEDICINE   AND    SURGERY 

Fig.  120. 


separated  as  scissors  "^ath  their  edges    reversed  for 
cutting   from   williin    outwards.       The   large  section 
(fig.  121)    in    which    the    blades 
^^*        *  have    been     partially    separated 

rirr^jt:::::-^^^^^  as  if   by    compression   upon   the 

/    - — =^^^^^       handles,    shows    the    manner    in 
^-^^^^  fu— --^^^^^^      which  the  lateral   section  of  one 
-^^  of  the  blades  has  been  arranged 

to  fortify  the  closed  instrument  when  used  as  a 
bocer  to  perforate  a  firm  scull,  and  to  prevent 
the  vibration  of  the  two  halves  of  the  instrument 
upon  each  other  as  occurs  in  Smellie's  scissors  while 
used  in  that  process ;  in  one  side  of  this  lateral  sec- 
tion is  a  conical  groove  into  which  a  conical  projec- 
tion from  the  other  blade  is  made  to  fit  accurately 
when  the  instrument  is  closed  by  the  wide  separation 
of  the  handles,  which  are  to  be  kept  thus  abducted 
by  the  commissure  of  the  thumb  and  fingers  being 
applied  at  the  crossing  of  the  stems  of  the  handles, 
while  the  point  of  the  instrument  is  carried  up, 
guarded  by  the  fingers  of  the  other  hand  to  the  part 
of  the  head  to  be  perforated.  The  instant  the  per- 
foration has  been  effected  by  such  rotary  motion  of 
the  instrument  as  may  be  necessary,  the  hand  is  to 
be  slided  from  the  stems  to  grasp  the  hanTiles,  and 
adducting  them  by  the  flexor  muscles,  the  blades  are 
separated  partially,  or  to  the  fullest  extent  as  may  be 
desired  or  as  may  be  practicable.  It  may  be  ob- 
served that  the  point  and  blades  of  Dr.  Ludlow's 
modification  of  the  German  instrument  operate  in  a 
similar  manner  with  that  just  described. 

How  is  the  uterus  to  be  supported  for  the  opera- 
tion ?  It  must  be  supported  by  one  or  both  hands  of 
an  assistant. 


OF   THE    LYIXG-IN    CHAMBER.  291 


HOW  TO  USE  THE  INSTRUMENT. 

Suppose  the  head,  &c.,  be  properly  supported  by 
the  hands  of  an  assistant  over  the  abdomen,  how  is 
the  operator  to  proceed  to  the  introduction  of  the 
instrument  ?  The  point  of  the  perforator,  or  scissors, 
is  to  be  well  guarded  by  one  hand  which  is  to  be 
introduced  to  the  proper  part  of  the  head. 

How  is  he  to  operate  with  it  ?  Fix  it,  if  possible, 
in  a  suture  or  fontanelle,  push  it  up  to  the  shoulders 
of  the  blades  if  he  use  the  scissors ;  then  open  the 
handles  and  cut  from  within  outwards,  then  turn  the 
edges  in  another  direction,  and  cut  again  till  he  has 
made  a  considerable  opening. 

When  you  have  perforated  to  the  cranium  suffi- 
ciently, how  are  you  to  break  up  the  membranes  and 
the  pulpy  mass  of  the  brain  ?  Pass  the  scissors,  or 
some  other  convenient  instrument  and  rotate  it  freely 
within  the  cranium,  at  the  same  time  scoop  out  the 
mass  thus  broken  up  hj  it. 

HOW  TO  AID  THE  COLLAPSE  OF  THE  CRANIAL  VAULT. 
If  the  head  do  not  readily  collapse,  what  means  of 
assistance  have  you  ?  The  application  of  the  forceps 
has  been  proposed,  and  in  some  cases  used  with  suc- 
cess, to  assist  in  compressing  the  cranial  bones  when 
they  have  not  readily  been  moulded  to  the  form  of 
the  pelvic  canal. 

VECTIS  IN  THESE  CASES. 

Could  you  ever  use  the  vectis  to  advantage  in  cases 
in  which  the  head  has  been  perforated  ?  It  may 
sometimes  be  used  with  benefit  to  change  the  direction 
of  the  head,  or  to  assist  in  traction. 

What  modification  of  vectis  did  Dr.  D.  D.  Davis 
make  for  this  purpose  ?  He  caused  a  number  of  sharp 
points  or  teeth  to  be  set  on  the  extremity  of  the  con- 
cave surface  and  nearly  at  right  angles  with  it,  for  the 
purpose  of  securing  a  firm   hold  on   the  part  of  the 


292  MEDICINE    AND    SURGERY 

scalp  or  cranial  bone  to  which  it  was  applied,  when 
used  either  as  a  lever  or  tractor. 

What  is  the  value  of  this  modification  in  practice  ? 
Such  an  instrument  could  rarely  be  useful,  as  it  would 
at  least  be  attended  with  embarrassment  should  the 
teeth  become  fastened  in  the  scalp  or  bone  while  the 
head  was  high  up,  or  pressed  against  the  wall  of  the 
pelvis. 

CROTCHET— HOW    USED. 

What  other  and  common  means  have  you  to  act  as 
a  tractor  ?  An  instrument  called  the  crotchet,  or 
sharp  hook. 

How  is  this  instrument  to  be  apphed  ?  It  is  to  be 
passed  through  the  artificial  opening  in  the  head,  and 
fixed  upon  some  firm  point  within  the  cranium.  It  is 
however  a  dangerous  instrument,  and  never  to  be  used 
when  it  can  be  avoided. 

How  are  you  to  guard  it  when  introduced  ?  By 
the  finger  applied  against  some  other  part  of  the 
head  to  prevent  any  accident  from  slipping. 

Are  crotchets  ever  guarded  by  a  blade  opposed  to 
them  ?  They  are ;  and  it  is  unsafe  to  use  one  without 
a  proper  guard  of  this  kind.     See  fig.  122. 

Fig.  122. 


HOW  TO  REMOVE  THE  CRANIAL  BONES. 

Suppose  there  is  not  room  for  the  bones  to  pass 
down  even  after  the  brain  is  evacuated,  what  then  is 
to  be  done  ?  Pick,  or  tear,  or  cut  away  the  different 
portions  of  the  vault  of  the  cranium. 

In  the  use  of  instruments  for  this  purpose,   should 


OF   THE    LYING-IN    CHAMBER. 


293 


you  have  regard  to  the  scalp  ?  Yes ;  it  is  important 
not  to  cut  it  away  with  the  bones,  but  preserve  it  as  a 
guard  to  the  soft  parts  of  the  mother. 

What  instrument  would  you  use  for  cutting  up  the 
bones  of  the  cranium  ?  The  craniotomist  of  Professor 
Davis  of  London,  (fig.  123)  of  which  the  spring  be- 
tween the  handles  has  been  added  by  Dr.  Warring- 


ton ;  or   the  curved   scissors   of  Professor  Hodge  of 
Philadelphia,  (fig.   124). 

Fig.  124. 


Suppose  the  space  is  too  small  for  you  to  operate 
with  the  craniotomist,  what  could  you  substitute 
for  it  ?  The  old-fashioned  duck-bill  forceps  of  the 
German  surgeon-accoucheurs,  shown  in  fig.  125;  or 

Fi-.  125. 


294 


MEDICINE    AND    SUrxGERY 


the  straiiQ^ht  and  curved  craniotomy  forceps,  devised 
by  Dr.  Meigs,  in  1831,  on  the  occasion  of  his  be- 
ing obliged  to  pick  away  the  cranial  bones  of  the 
child  of  Mrs.  R.,  whose  case  is  amply  detailed  in 
his  work  on  obstetrics,  (page  570,  edition  of  1852,) 
and  upon  whom  the  cesarean  section  has  since  been 
twice   successfully  performed. 

Fig.  126. 


OF   THE    LYING-IN    CHAMBER.  295 


OPERATE  DELIBEHATELY. 

When  tills  difficult  operation  has  been  decided  upon, 
is  it  necessftry  for  you  to  complete  it  at  once  ?  Gene- 
rally the  operator  may  take  his  time  at  it,  work  at  it 
till  he  is  weary,  then  give  his  patient  an  anodyne,  rest 
her  and  himself,  and  afterwards  resume  the  task. 

Through  what  sized  aperture  can  you  bring  down 
the  base  of  the  cranium  ?  One  that  is  from  one  and 
a  quarter  to  one  and  a  half  inches  antero-posteriorly, 
and  from  two  and  a  half  to  three  inches  transversely. 

Is  the  operation  of  cephalotomy  dangerous  to  the 
mother  ?  Not  in  common  cases,  if  performed  in  time 
and  with  proper  care. 

Is  her  situation  hazarded  by  the  necessity  of  break- 
ing up  the  vault  of  the  cranium  ?  It  is,  unless  great 
care  is  taken  to  adjust  the  instrument  safely. 

Suppose  the  body  will  not  pass  through  the  de- 
formed canal  ?     It  must  then  be  mutilated. 

Should  you  make  up  your  mind  in  the  early  part 
of  labor,  in  what  manner  you  will  complete  the  de- 
livery ?  It  is  proper  that  you  make  a  careful  exami- 
nation for  that  purpose. 

TRY  FORCEPS  FIRST   IF  POSSIBLE. 

Suppose  the  pelvis  be  rather  smaller  than  the  stand- 
ard size,  what  should  be  done  when  labor  takes  place? 
Clear  the  bowels  and  the  bladder,  promote  relaxation 
of  the  soft  parts — make  a  careful  examination  of  the 
internal  capacity  of  the  pelvis — and  if  it  be  regular 
and  not  very  small,  some  hope  may  be  entertained 
that  the  child  may  be  extracted  without  being  previ- 
ously mutilated. 

If  the  blades  of  the  forceps  could  be  introduced,  do 
you  think  it  prudent  to  try  the  use  of  them  ?  Yes — 
in  all  cases  in  which  the  capacity  of  the  pelvis  will 
admit  of  the  application  of  forceps,  it  will  be  best  to 
make  compression  and  traction  by  means  of  them. 

Suppose  you  had  applied  the  forceps,  and  found 


296  MEDICINE    AND    SURGERY 

you  could  not  deliver  with  them,  how  should  you  do  ? 
Open  the  head  while  the  forceps  are  still  on,  then 
compress  the  bones  with  these  instruments,  and  renew 
the  attempt  to  deliver. 

Suppose  the  size  of  the  pelvis  he  so  small  that  you 
cannot  introduce  the  forceps,  what  should  you  do? 
Diminish  the  size  of  the  child's  head,  and  then  apply 
the  crotchet  or  the  craniotomy  forceps. 

What  instrument  have  you  to  diminish  the  size  of  the 
child's  head  in  utero,  besides  that  of  the  perforator 
or  ordinary  forceps  ?  The  crushing  forceps,  brise- 
tete  or  cephalotribe  of  A.  C.  Baudelocque. 

Would  you  be  disposed  to  use  this  instrument  ?  It 
is  so  large  and  cumbrous  an  instrument,  that  we  think 
it  could  not  be  used  without  great  hazard  to  the  pa- 
tient, though  it  is  said  to  have  been  successfully  em- 
ployed in  some  cases  in  Paris. 

Is  it  probably  not  susceptible  of  some  reduction  of 
its  size,  and  thus  be  better  adapted  to  use  ?  Under 
direction  of  Professor  Hodge,  the  instrument  has  been 
much  reduced  in  size,  by  Mr.  John  Rorer  and  Sons, 
without  material  loss  of  power,  and  has  several  times 
been  used  in  Philadelphia  in  bringing  heads  through 
the  pelvis,  after  protracted  attempts  with  well  made 
forceps  had  failed. 

DR.  HODGE'S  COMPRESSORES  CRANII. 

What  appears  to  be  the  reason  which  led  Professor 
Hodge  to  modify,  improve,  and  render  practical  the 
heavy  and  otherAvise  inconvenient  Brise  tete  of  A.  C. 
Baudelocque ?  He  says,  I  was  called  in  18 —  to  as- 
sist in  consultation,  at  the  delivery  of  a  young  wo- 
man with  her  first  child,  who  had  been  in  labor  for 
five  days.  After  three  da3^s,  the  pains  had  entirely 
subsided,  and  could  not  be  re-excited  even  by  large 
doses  of  the  secale  cornutum. 

The  presentation  was  the  head  at  the  superior 
strait,  but  what  part  could  not  be  exactly  recognized. 
A  strong  pair   of  Baudelocque's  forceps  was   applied 


OF    THE    LYING-IN    CHAMBER.  297 

at  the  sides  of  the  pelvis,  and  moderate  tractive  efforts 
soon  convinced  me  that  the  head  was  too  firmly 
"locked  "  to  be  moved.  I  was  unwilling  to  abandon 
the  firm  hold  on  the  head  by  the  forceps,  and  deter- 
mined therefore  to  puncture  the  head  without  remov- 
ing the  instrument.  This  being  accomplished,  strong 
compression  was  made  by  the  fillet  to  the  handles  of 
the  forceps,  and  in  a  short  time  the  head  descended, 
and  was  delivered  without  difficulty — transversely, 
the  face  to  the  right  tuber  ischii,  the  occiput  to  the 
left,  so  great  was  the  diminution  of  the  occipito-fron- 
tal  diameter  by  the  blades  passed  over  the  two  extre- 
mities of  the  head.  The  success  of  the  operation,  the 
short  time  occupied,  the  comparative  facility  of  exe- 
cution compared  with  the  usual  operation  by  means  of 
crotchets  and  craniotomy  forceps,  determined  me  to 
repeat  the  experiment.  On  several  minor  occasions  it 
answered.  In  1842  a  more  serious  case  occurred  in  a 
woman  with  a  contracted  pelvis,  measuring  three 
inches  in  the  antero-posterior  diameter  of  the  supe- 
rior strait,  to  Dr.  Warrington,  who  politely  requested 
my  assistance.  Dr.  W.  opened  the  head  and  applied 
the  forceps.  The  instrument  was  not  sufficiently  pow- 
erful immediately  to  effect  our  purpose.  Fortunately, 
however,  by  continued  pressure,  the  left  parietal  bone 
collapsed,  when  delivery  was  safely  and  easily  accom- 
plished. 

The  superiority  of  this  mode  of  delivery  was  to  me 
sufficiently  evident,  and  having  heard  of  the  "brise- 
t^te  "  of  Baudelocque,  Jun.,  I  procured  a  specimen 
from  Paris,  which  proved  to  be  so  very  large,  heavy, 
and  awkward,  that  I  did  not  venture  to  use  it.  Re- 
flection on  the  dangers  of  the  usual  mode  of  delivery 
by  tractors,  after  craniotomy,  and  on  those  by  com- 
pression, so  perfectly  satisfied  me,  that  the  latter  were 
far  less,  in  every  respect,  determined  me  to  have  a 
strong  pair  of  forceps  made  for  effectually  crushing 
the  head  of  the  child,  so  as  to  relieve  the  tissues  of 
the  mother  as  much  as   possible,   from   the   effects  of 


298  MEDICINE   AND    SURGER  . 

pressure,  in  these  unfortunate  cases,  and  yet  small 
enough  to  be  readily  and  safely  used  by  any  one  ac- 
customed to  the  use  of  the  common  long  forceps  at 
the  superior  strait. 

Our  excellent  obstetric  instrument-maker,  Mr. 
Rorer,  No.  24  North  Sixth  street,  has  successfully 
carried  out  my  ideas  in  the  manufacture  of  a  pair  of 
strong  forceps  on  the  model  of  Baudelocque's  "  brise 
t^te."  Experiments  on  dead  infants,  first  made  after 
delivery,  and  subsequently  before  delivery,  evince  the 
facility  and  safety  of  its  employment,  and  also,  that 
it  has  sufficient   power. 

Although  much  heavier  than  the  common  forceps 
for  the  purpose  of  strength,  yet  the  "  compressores 
cranii"  are  of  much  easier  application,  as  their  di- 
mensions are  smaller  and  the  blades  may  be  passed 
up  in  any  direction  where  there  is  most  room — it  be- 
ing indifferent  to  what  part  of  the  head  they  are  ap- 
plied. The  action  of  the  instrument  is  two-fold — 
first,  to  compress,  and  thus  break  up  the  cranium 
and  reduce  its  diameters,  if  needs  be,  to  two 
inches,  which  experience  shows  may  be  done  without 
any  danger  of  the  crushed  fragments  of  the  cranium 
dividing  the  scalp  of  the  child  and  penetrating  the 
soft  parts  of  the  mother.  They  fall  inward.  Second, 
They  operate  as  "  tractors''  in  the  same  manner  as  the 
common  forceps  ;  care  being  taken  to  deliver  slowly, 
that  no  undue  or  irregular  pressure  be  made  on  the 
perinaeum,  rectum,  vulva,  &c. 

The  general  appearance  of  the  compressores  cranii 
resembles  the  French  long  forceps  with  the  double 
curve  ;  each  curve  being  somewhat  modified.  The  pel- 
vic curve  is  less,  allowing  more  strength  to  the  instru- 
ment. The  cephalic  curve  is  modified  on  the  same 
principle  as  that  of  the  ^'eclectic  forceps,"  (quod 
vide)  so  that  when  the  handles  are  in  contact,  an  oval 
space  exists  between  the  blades,  six  inches  and  five 
tenths  long,  the  greatest  breadth  being  at  a  point 
three   inches   and  three  quarters  from  the  extremity 


OF   THE    LYING-IN    CHAMBER.  299 

and  but  two  inches  and  three  quarters  from  the  com- 
mencement of  the  cephalic  curve  nearest  the  joint  of 
the  instrument,  corresponding  to  the  oval  form  of  the 
head,  and  having  the  mechanical  effect  of  forcing  the 
head,  as  it  is  diminished  in  size,  more  and  more  into  the 
grasp  of  the  blades.  The  blades  are  solid  for  strength ; 
fenestra  are  not  here  wanted.  They  measure  6.5  inches 
in  length ;  their  greatest  breadth  is  1.5  inch,  at  an 
inch  from  their  termination,  rery  gradually  dimin- 
ishing towards  the  lower  portion  near  the  joint ;  and 
.25  of  an  inch  in  thickness.  The  external  surface  is 
convex  and  perfectly  smooth ;  the  internal  concave. 
When  closed,  the  greatest  breadth  of  the  instrument 
is  2  inches ;  hence  the  closed  instrument  could  be 
drawn  through  an  orifice  two  inches  in  diameter.  The 
shanks  of  the  blades,  from  the  termination  of  the  cepha- 
lic curve  to  the  centre  of  the  joint,  measure  3.5  inches, 
making  the  whole  distance  from  the  joint  to  the  ter- 
mination of  the  blades,  10  inches.  The  handles  of 
the  instrument  are  strong,  flat,  generally  .75  of  an  inch 
wide  and  9.5  inches  in  length :  thus  making  the 
whole  instrument  19.5  inches  long.  The  extremities 
of  the  handles  are  enlarged  slightly  and  perforated 
so  as  to  admit  a  moveable  screw.  This  is  fixed  on  the 
left  blade  by  means  of  a  small  pivot, while  a  burr  or  nut, 
with  lever-like  handles,  plays  on  the  screw,  being  very 
light,  easily  managed  by  the  fingers,  and  very  powerful. 
In  the  most  gradual,  yet  in  the  most  efficient  manner, 
can  the  blades  be  brought  together  by  this  combined 
action  of  the  screw  and  lever.  The  force  can  be  re- 
gulated with  the  utmost  precision. 

The  joint  is  similar  to  that  of  the  German  forceps, 
with  a  conical,  but  fixed  pivot.  To  strengthen  the 
instrument,  at  this  point,  where  the  force  is  most 
concentrated,  the  instrument  is  here  broader  and 
thicker,  and  to  maintain  the  parallelism  of  the  blades, 
not  only  are  the  surfaces  at  the  joints  broad  and  flat, 
but  a  very  large  button  is  affixed  to  the  top  of  the 
pivot,    preventing    tlie    twisting    of    the    blades    on 


800  MEDICINE    AND    SURGERY 

each  other.  The  weight  of  the  instrument  is  three  lbs. 
two  ounces. 

Fig.  127  gives  a  profile-view  of  the  instrument, 
slightly  turned  to  show  the  upper  edge  of  the  clam 
of  the  left-hand  branch.  The  shanks,  lock,  and  a 
section  of  the  handle,  are  also  shown  in  this  figure. 

Fig.  128,  exhibits  the  entire  instrument,  as  seen 
from  above,  completely  closed. 

Fig.  129,  represents  a  section  of  the  instrument  as 
seen  from  above,  with  the  clams  applied  upon  the 
two  sides  of  a  firm  fetal  cranium. 

Fig.  130,  exhibits  the  burr  or  nut,  intended  to 
work  upon  the  screw  for  approximating  the  handles 
when  the  instrument  is  in  use ;  /  is  the  orifice  of  the 
female  screw,  cut  through  the  centre  of  the  burr ; 
g^  g^  g^  are  the  lever-like  handles,  about  one  inch 
and  three  quarters  long,  having  bulbs  at  their  outer 
extremities. 

Fig.  131,  represents  a  screw  about  five  inches 
long,  intended  to  be  joined  to  an  oblong  opening 
in  the  extremity  of  the  handles  of  the  left  hand 
or  male  branch  of  the  instrument,  by  its  flattened 
extremity,  li,  at  which  is  seen  also  a  hole  through  w^hich 
a  small  thumb-screw  (fig.  132)  is  to  pass  to  secure  it  in 
its  place.  The  shaft  of  the  screw  represented  in  this 
figure,  is  to  be  passed  through,  and  have  free  play  in 
a  still  more  oblong  opening  in  the  end  of  the  handle 
of  the  female,  or  right-hand  branch  of  the  instrument, 
after  it  has  been  applied  upon  the  part  it  is  intended 
to  compress  or  crush. 

Fig.  132,  displays  the  thumb-screw  to  be  passed 
through  a  circular  opening  on  the  extremity  of  the  male 
blade,  and  also  through  the  circular  opening  at  the 
end  of  the  screw,  shown  in  the  immediately  preceding 
figure. 

In  the  figs.  127,  128  and  129,  a  b  show  the  clams; 
h  c,  the  shanks  of  the  clams ;  d  d,  the  handles,  in  part 
and  entire ;  and  e,  the  broad  flat  button  on  the  top  of 
the  strong  pivot  fixed  in  the  male  blade,  and  ofl'ering 


OP   THE    LYI>^G-IN    CHAMBER. 


301 


its  neck  to  be  embraced   bj  the  notch  of  the  female 
blade  or  branch  of  the  instrument. 


Fig.  127.        Fig.  128. 


Fig.  129. 


Fig.  131. 
26 


302  MEDICINE   AND    SURGERY 


ERGOT,  NOT  PROPER. 

Should  you  ever  use  ergot  in  cases  of  considerable 
deformity  of  the  pelvis  ?  Never,  inasmuch  as  there 
would  be  great  danger  of  rupturing  the  uterus  if 
ergotic  contractions  were  to  be  induced. 

VERSION  BY  THE  FEET  IN  DEFORMITIES  OF  THE 
PELVIS. 

Should  you  perform  version  by  the  feet  in  such 
cases  ?  The  propriety  of  this  practice  is  at  least 
doubtful. 

What  would  be  the  objection  to  this  practice  ?  We 
should  increase  the  difficulty,  if  there  was  not  room 
for  the  child  to  pass,  by  removing  the  head  from  the 
reach  of  instruments '  intended  to  draw  upon  it  or 
diminish  its  size. 

Who  has  strongly  advocated  the  propriety  and  ad- 
vantage of  turning  with  the  view  to  bring  down  the 
feet  in  cases  of  contracted  upper  strait  ?  Professor 
Simpson,  of  Edinburgh. 

PROFESSOR  SIMPSON'S  ARGUMENT. 

What  are  his  arguments  in  favor  of  this  procedure  ? 

1.  The  fetal  cranium  is  of  a  conical  form,  enlarging 
from  below  upwards,  and  when  the  child  passes  as  a 
footling  presentation,  the  lower  and  narrower  parts 
of  the  cone-shaped  head  is  generally  quite  small 
enough  to  enter  and  engage  in  the  contracted  brim. 

2.  The  hold  which  we  have  of  the  protruded  body  of 
the  child,  after  its  extremities  and  trunk  are  born, 
gives  us  the  power  of  employing  so  much  extractive 
force  and  traction  at  the  engaged  fetal  head,  as  to 
make  the  elastic  sides  of  the  upper  and  broader  parts 
of  the  cone  (viz.,  the  biparietal  diameter  of  the  cra- 
nium) become  compressed,  and,  if  necessary,  indented 
b(3tween  the  opposite  parts  of  the  contracted  pelvic 
brim,  to  such  a  degree  as  to  allow  the  transit  of  the 
entire  volume  of  the   head.     3.  The  head  in  being 


OF   THE    LYING-IN   CHAMBER.  303 

arranged  downwards  into  the  distorted  pelvis  gene- 
rally arranges  itself,  or  may  be  artificially  adjusted 
so  that  its  narrow  bi-temporal,  instead  of  its  broad 
bi- parietal  diameter,  becomes  engaged  in  the  most 
contracted  diameter  of  the  pelvic  brim.  4.  The  arch 
of  the  cranium  or  head  is  more  readily  compressed 
to  the  flattened  form  and  size  required  for  its  passage 
through  a  contracted  brim,  by  having  the  compress- 
ing power  applied  as  in  footling  cases  and  extraction, 
directly  to  its  sides  or  lateral  surfaces,  than  by  hav- 
ing it  applied  as  in  cephalic  presentations,  partly  by 
the  lateral  and  partly  to  the  upper  surfaces  of  the 
arch. 

PREMATURE  ARTIFICIAL  DELIVERY. 

What  other  plan  does  obstetric  medicine  propose 
to  prevent  the  occasion  for  the  use  of  instruments  in 
cases  of  deformed  pelvis  ?  The  induction  of  artificial 
premature  delivery; 

What  is  the  proper  stage  of  pregnancy  for  this 
purpose  ?     The  eighth  month  or  a  little  earlier. 

What  is  the  proper  mode  of  doing  this  ?  Stimulate 
the  uterus  to  contraction,  by  titillating  the  internal 
surface  of  the  os  uteri — or,  if  this  do  not  succeed,  by 
puncturing  the  membranes. 

What  modes  have  been  proposed  as  most  suitable 
for  exciting  the  contraction  of  the  uterus,  when  it  has 
been  carefully  decided  to  be  proper  to  promote  deli- 
very prematurely?  Professor  Hamilton  of  Edin- 
burgh, was  in  the  practice  of  introducing  a  finger 
into  the  os  uteri  every  day  or  two,  till  he  excited  the 
contractions  sufficiently.  Professor  Simpson  used 
sponge  tents  for  the  same  purpose.  Others  have  re- 
sorted to  bougies,  or  flexible  metallic  sounds,  and 
carried  them  up  some  distance  between  the  mem- 
branes and  the  internal  surfaces  of  the  uterus. 

Is  it  safe  to  puncture  the  membranes,  while  the  os 
and  part  of  the  cervix  uteri  is  still  closed  ?  It  is  not 
prudent  to  rupture  the  membranes;  if  it  can  possibly 


B04  MEDICINE   AND    SURGERY 

be  avoided,  before  the  os  uteri  is  dilated  to  some 
extent,  and  appears  to  be  readily  dilatable. 

What  are  the  probable  chances  for  the  life  of  the 
child  when  delivered  thus  in  the  course  of  the  eighth 
month  of  gestation  ?  So  far  as  information  has  been 
collected  on  this  subject,  it  appears  that  only  about 
one  in  two  of  children  thus  born,  are  delivered  alive. 

What  size  of  the  pelvis  demands  this  practice  if 
you  aim  to  avoid  the  hazards  to  the  mother  by  the 
operation  of  hysterotomy?  When  the  diameter  is 
less  than  three  inches,  say  two  and  three  quarter 
inches  antero-posteriorly. 

Suppose  the  diameter  be  less  than  this,  what  must 
you  have  recourse  to  ?  To  gastro-hysterotomy,  i.  e. 
the  cesarean  section ;  or  to  the  use  of  the  crotchet. 

Should  you  ever  attempt  either  of  these  operations 
while  alone  ?  Never,  if  possible  to  have  a  consulta- 
tion. 

When  the  pelvis  is  very  much  contracted,  which  is 
to  be  preferred,  the  crotchet  or  the  cesarean  section  ? 
If  the  child  be  alive,  and  the  mother  in  good  condi- 
tion, it  would  be  right  to  recommend  the  cesarean 
section. 

CESAREAN  SECTION,  OR  GASTRO-HYSTEROTOMY. 

What  i'=5  meant  by  the  phrase  cesarean  section^  or 
gastro-hysterotomy?  That  section  of  the  abdomen 
and  uterus  through  which  the  fetus,  or  the  fetus  and 
placenta,  may  be  removed,  solely  with  a  view  to  save 
the  life  of  the  child,  because  the  mother  is  already 
recently  dead,  or  because  the  natural  passages  are  so 
diminutive  that  it  is  impossible  to  remove  the  child, 
however  much  mutilated,  through  them,  without  ine- 
vitable destruction  of  the  life  of  the  mother  also. 

OBJECTIONS  TO  THE  OPERATION. 

What  are  the  objections  to  the  cesarean  section  ? 
First,  it  involves  the  life  of  the  mother  in  great  jeo- 
pardy, particularly  if  resorted   to  when  she  is  in  a 


OF   THE    LYING-IN    CHAMBER.  305 

state  of  excitement  or  exhaustion  from  ineifectual 
labor.  Second,  it  does  not  always  preserve  the  life 
of  the  child,  though  the  risk  of  this  is  the  least 
objection. 

TIME  PROPER  FOR  PERFORMING  IT. 
If  it  appear  clearly  the  duty  of  the  consultation  of 
accoucheurs  that  the  operation  is  necessary,  when 
should  it  be  performed  ?  At  as  early  a  period  of 
labor  as  possible.  It  is  particularly  desirable  that 
the  patient  should  have  been  subjected  to  as  little 
fatigue  from  parturient  effort  as  possible,  previous  to 
being  subjected  to  so  important  an  operation. 

ACCIDENTS  ATTENDANT  UPON  THE  THIRD  STAGE  OP 
LABOR— RISKS  FROM  TOO  LONG  DELAY  IN  THE  DE- 
LIVERY OF  THE  PLACENTA. 

What  hazards  are  known  to  result  from  the  practice 
of  leaving  the  placenta  in  the  uterus  until  spontane- 
ous expulsion  takes  place  ?  Irritation,  inflammation, 
low  fever,  &c. 

Should  you  ever  leave  your  patient  so  long  as  the 
placenta  remains  undelivered  ?  She  should  not  be  left 
more  than  a  few  minutes  at  a  time,  because,  although 
in  some  cases  no  accident  has  happened  from  a  long 
continued  retention,  it  is  proper  you  should  guard 
against  dangers  by  proper  attempts  to  remove  it  early 
after  the  child  has  been  born. 

MANAGEMENT  OF  SUCH  CASES. 

What  practice  is  best  for  relaxing  the  mouth  of  the 
uterus,  and  for  inducing  the  contraction  of  the  fundus 
and  the  body  ?  Friction  over  the  body  of  the  ute- 
rus ;  the  application  of  cold  by  sponges  of  cold  water 
or  by  a  stream  of  cold  water  from  a  height,  &c. 

Is  the  practice  of  making  cold  and  wet  applications 
upon  the  abdomen  hazardous  under  such  or  any  other 
circumstances,  except,  perhaps,  when  the  patient  has 
inflammation  of  the  abdomen  or  viscera  within  it? 
Many  experienced  practitioners  have  doubted  the  pro- 
26* 


306  MEDICINE   AND   SURGERY 

priety  of  the  sudden  application  of  cold  to  a  part  of 
the  body  usually  carefully  protected  by  warm  clothing, 
and  some  express  their  belief  that  serious  conse- 
quences have  resulted  from  the  employment  of  it  in 
the  cases  now  under  consideration. 

What  should  you  do  if  external  frictions  and  the  use 
of  cold  do  not  succeed  ?  Pass  in  the  whole  hand  cau- 
tiously, and  seize  the  placenta  with  the  fingers  and 
bring  it  down  ;  provided,  however,  the  insertion  of  one 
or  more  fingers  has  not  been  sufficient  to  effect  this 
purpose. 

MANAGEMENT  OF  THE   PLACENTA  WHEN    THE    CORD    IS 
RUrTURED. 

Is  the  cord  sometimes  so  tender  as  to  be  very  easily 
broken  ?  It  is  in  some  cases  severed  by  the  slightest 
traction  upon  it. 

What  practice  should  you  resort  to  for  the  purpose 
of  removmg  the  placenta  in  the  case  of  rupture  of  the 
cord  ?  The  fingers  or  the  hand  should  be  carefully 
introduced  within  the  vagina,  and  if  necessary,  within 
the  cavity  of  the  uterus,  and  made  cautiously  to  em- 
brace as  much  of  the  mass  as  practicable,  at  the  same 
time  allowing  the  uterus  to  expel  it  if  possible ;  if  not, 
draw  it  gradually  in  the  direction  of  the  axis  of  the 
part  through  which  it  is  to  pass. 

RETENTION  OF  THE  PLACENTA. 

Is  retention  of  the  placenta  ever  dependant  upon 
the  manner  in  which  its  fetal  surface  ofiers  to 
the  OS  uteri?  There  is  strong  reason  to  believe 
that  in  numerous  instances  of  retention  of  the  pla- 
centa, or  the  delay  in  its  expulsion  is'  owing  to  the 
fact  that  the  centre  of  the  disc  offers  to  the  os  uteri 
and  th_|  circumference  is  too  great  to  be  allowed  to 
pass  through  the  orifice  of  the  uterus. 

MANAGEMENT  OF  RETENTION  OF  THE  PLACENTA. 

What  are  the  duties  of  the  accoucheur  in  such 
cases  ?     First   to  examine  the  situation   of  the  pla- 


OF  THE   LYING-IN   CHAMBER.  307 

centa,  and  if  it  offers  in  the  manner  proposed,  en- 
deavor to  fix  the  curved  extremity  of  a  finger  into 
some  marginal  point  of  the  mass,  make  traction  on  it 
and  so  arrange  it  that  it  shall  offer  that  edge  to  the 
axis  of  the  uterus. 

In  attempting  to  do  this,  would  not  inversion  of  the 
womb  be  hazarded  ?  Not  at  all  if  the  operator  do  his 
duty  skilfully,  making  the  entire  change  of  the  form 
and  position  of  the  placenta  within  the  uterine  cavity, 
the  opposite  hand  being  kept  on  the  abdomen  over  the 
anterior  part  of  the  body  and  fundus  of  the  uterus, 
especially  if  the  operator  keeps  in  mind  the  principle 
that  the  change  in  the  form  and  relations  of  the  pla- 
centa is  to  be  effected  within  the  cavity  of  the  con- 
taining organ,  and  without  any  tractive  force  in  the 
direction  of  its  axis. 

COAGULA  BETWEEN  THE  PLACENTA  AND  UTERUS. 

Does  the  presence  of  the  coagula  behind  the  pla- 
centa, seem  to  retard  its  delivery  ?  This  has  been 
regarded  as  one  of  the  causes  of  delay  in  its  expulsion. 

Are  there  any  positive  means  for  diagnosticating 
the  existence  of  effused  blood  between  the  placenta 
and  the  uterus  ?  Most  commonly  this  is  only  sus- 
pected when  a  part  of  the  placenta  can  be  felt  at  the 
orifice,  while  the  body  is  still  large  and  the  fundus  is 
high  up  in  the  abdomen.  The  only  positive  assurance 
that  there  is  more  or  less  blood  effused,  is  derived 
from  the  observation  that  it  escapes  in  greater  or 
less  quantity  by  the  side  of  the  placenta  through  the 
vagina. 

WHAT  TO  DO  IN  SUCH  CASES. 

How  should  suspicion  or  proof  of  the  existence  of 
fluid  or  coagulated  blood  behind  the  patient  influence 
the  conduct  of  the  attendants  upon  the  patient  ?  The 
suspicion  of  it  should  prompt  the  accoucheur  to  sa- 
tisfy himself  of  the  patient's  general  condition,  espe- 
cially in  regard  to  the  fulness  and  regularity  of  her 


308  MEDICINE   AND    SURGERY 

pulse,  and  by  auscultation  to  determine  if  possible 
that  there  is  not  a  second  ovum  above  the  placenta  ; 
then  to  insure  contraction  of  the  uterus,  he  or  the 
nurse  should  make  free  friction  over,  and  even  com- 
pression upon,  the  abdominal  tumor,  to  promote  the 
rapid  and  strong  tonic  contraction  of  the  uterus.  At 
the  same  time  he  should  pass  a  hand  along  the  vagina 
into  the  os  uteri  if  necessary,  seize  the  placenta, 
and  by  a  gentle  but  firm  effort  hold  and  draw  it 
down. 

•  CONTRACTION  OF  THE  OS  UTERI  BEFORE  THE  PLACENTA 
IS  DELIVERED. 

Does  the  contraction  of  the  os  uteri  ever  pre- 
vent the  delivery  of  the  placenta  ?  This  is  pro- 
bably a  rather  frequent  cause  of  retention  of  the 
placenta. 

What  varieties  of  contraction  are  there  of  the  os 
uteri  ?  That  of  the  internal  and  that  of  the  external  os 
uteri. 

How  do  you  ascertain  this  ?  By  the  sense 
of  touch  upon  introducing  a  finger  within  the 
orifice. 

HOW  TO  ACT  IN  SUCH  CASES. 

What  course  should  the  accoucheur  pursue  in  case 
he  finds  the  os  uteri  contracted  upon  the  cord,  and  the 
placenta  thereby  shut  up  in  the  uterus  ?  ^f  the  con- 
traction is  only  very  recent  and  the  ring  of  the  os 
uteri  is  not  very  rigid,  it  will  be  his  duty  to  hold  the 
cord  in  one  hand,  while  he  passes  the  other  in  the 
form  of  a  hollow  cone  with  the  cord  in  the  centre,  and 
by  this  as  his  guide,  gently  but  steadily  carry  first  the 
fingers  and  next  the  whole  hand  into  the  orifice,  as  he 
gradually  enlarges  it  till  he  can  embrace  the  placenta 
by  his  then  expanded  fingers  ;  this  done,  he  must 
make  a  careful  rotary  and  downward  traction  upon 
the  mass,  until  he  has  brought  it  through  the  os  uteri 
into  the  vagina. 


OF   THE   LYING-IN    CHAMBER.  309 

How  should  the  fundus  of  the  uterus  be  supported 
while  both  his  hands  are  thus  employed  ?  By  the  well 
directed  application  of  the  hands  of  the  nurse  or 
some  other  attendant,  until  his  hand  is  fairly  intro- 
duced, but  afterwards  by  the  hand  which  was  at  first 
occupied  in  holding  the  cord  tense. 

Should  the  hand  be  made  to  descend  first,  bringing 
the  placenta  with  it  ?  To  avoid  the  dreadful  accident 
of  dragging  down  the  fundus  of  the  uterus  and  caus- 
^  ing  partial  or  complete  inversion  of  the  organ,  it  is 
always  most  prudent  for  the  operator  to  take  great 
care  that  the  placenta  is  made  to  pass  from  his  flexed 
fingers  by  the  hollow  of  his  hand  and  wrist  at  least 
into  the  vagina,  that  he  may  perceive  by  the  hand  in- 
ternally, and  the  contour  of  the  uterus  externally, 
that  it  has  contracted  regularly  from  its  circumference 
to  its  centre  before  he  withdraws  entirely  the  hand 
which  had  been  introduced. 

What  instrument  may  be  used  to  assist  in  extract- 
ing the  placenta  in  these  cases  ?  The  placental  hook 
or  wire  crotchet  of  the  late  Professor  Dewees,  as 
shown  in  fig.  133. 

Fig.  133. 


What  are  the  objections  to  the  use  of  this  hook  ? 
It  would  seem  to  be  a  dangerous  instrument  unless 
when  very  carefully  used,  since,  if  its  point  be  passed 
beyond  the  end  of  the  finger  it  may  be  hooked  into 
the  substance  of  the  uterus,  and  sometimes  when 
apparently  well  fixed,  tears  out  without  doing  more 
than  lacerating  the  placenta  or  the  parts  adjoining 
to  it. 

What  instruments  have  been  proposed  as  a  substi- 
tute for  this  crotchet  ?  Dr.  Bond's  forceps,  of  which 
a  drawing  is  shown  in  fig.  134. 

What  advantage  does  this  instrument  offer  over  the 
crotchet  of  Dewees  ?     Being  curved  nearly  to  corres- 


310  SURGERY    AND    MEDICINE 

pond  with  the  axis  of  the  pelvis,  it  may  be  introduced 
with  more  facility  into  the  cavity  of  the  uterus,  along 
the  hand  or  fingers,  and  when  inserted  properly,  by 
expanding  the  blades  they  may  be  made  to  embrace 
a  portion  of  the  placenta  within  their  serrated  lips,  and 

Fig.  134. 


when  traction  is  made  upon  them,  if  they  cannot  bring 
the  whole  mass  away  at  once,  their  withdrawal  subjects 
the  patient  to  no  hazard  of  injury. 

RETENTION   OF   PLACENTA  FROM  IRREGULAR  CONTRAC- 
TION OF  THE  UTERUS. 

What  is  the  consequence  of  very  violent  and  irre- 
gular contraction  of  the  body,  as  well  as  of  the  neck 
of  the  uterus  ?  Prostration  of  the  patient's  strength, 
great  exhaustion,  faintness,  &c. 

What  should  we  rely  upon  most  confidently, 
for  the  relaxation  of  such  spasm  ?  Free  doses  of 
opium. 

May  contraction  ever  take  place  at  the  internal  os 
uteri  ?  It  may,  and  perhaps  most  frequently  does  in 
cases  of  retention  of  the  placenta. 

How  should  we  overcome  this  constriction  ?  By 
the  gradual  insertion  of  the  fingers,  and  perhaps  the 
whole  hand  cautiously.  In  some  cases  bleeding  and 
other  relaxing  measures  are  necessary. 

What  other  part  of  the  uterus  may  become  spas- 
modically contracted  ?  Any  other  parts  of  the  body 
of  the  uterus. 


OF   THE   LYING-IN    CHAMBER.  311 


HOURGLASS  CONTRACTION. 

What    is   the   peculiar     con-  Fig.  135. 

traction  called,  in  which  the 
fibres  of  the  middle  portions 
of  the  body  contract,  while  the 
other  portions  remain  some- 
what relaxed  ?  Hourglass  con- 
traction. 

Is  there  any  danger  of  he- 
morrhage in  this  case?  Hemor- 
rhage may  take  place  both  above 
and  below  the  constricted  part. 
This  complication  is  probably 
rare. 

Does   this   kind   of    accident 
require  prompt  attention  ?      It 
should  be  attended  to  promptly, 
because  it  usually  is  a  case  accompanied  with  much 
suffering. 

What  have  you  to  do  to  overcome  it  ?  By  fric- 
tions on  the  abdomen,  induce  the  fundus  to  contract, 
then  introduce  your  other  hand  into  the  uterus 
and  pass  it  up  conically  through  the  point  of  stric- 
ture. 

Should  you  try  to  pull  the  placenta  away  instantly  ? 
Efforts  should  be  made  to  extract  it  cautiously,  and 
allow  the  contractions  to  take  place  regularly,  as  the 
mass  is  removed. 

How  should  you  secure  the  regular  contractions 
of  the  uterus,  while  the  hand  is  still  in  it?  By 
proper  frictions  upon  the  abdominal  parieties  over 
the  fundus  of  the  uterus,  while  a  hand  is  in  the  free 
portions  of  its  cavity,  if  possible. 

How  should  you  effect  the  relaxation  of  the  stric- 
ture, if  the  means  just  proposed  do  not  succeed  ? 
Put  the  patient  into  a  warm  bath,  give  her  opiates, 
or  bleed  her. 


312 


MEDICINE   AND   SURGERY 


Fio;.  136. 


ADHESION  OF  THE  PLACENTA. 

Is  preternatural  adhesion  of  the  placenta  very 
common  ?  It  is  probably  not  by  any  means  so  com- 
mon as  is  supposed  by  initial  or  inexperienced  practi- 
tioners. 

Is  the  diagnosis  of  such  adhesion  easy  ?  It  is  not 
always  easily  made  out. 

HOW  TO  TREAT  ADHERENT  PLACENTA. 

How  should  you  act  in  a  case  of  real  or  sup- 
posed adhesion  of  the  placenta  ?  Pass  up  the  hand 
in  a  conical  form,  and  when  you  reach  the  part, 
expand  it. 

Which  portion  of  your  fingers 
should  you  place  in  contact  with 
the  uterus,  in  order  to  detach 
the  placenta  ?  The  pulpy  por- 
tion when  you  can,  but  as  this 
would  be  difficult  when  the  pla- 
centa is  at  the  fundus,  it  will 
almost  always  be  more  effectual 
to  keep  the  dorsum  of  the  hand  to 
the  walls  of  the  uterus,  and  the 
inner  surface  of  it  to  the  pla- 
centa, (as  shown  in  fig.  136.) 

Suppose  the  adhesions  are  very 
firm,  should  you  attempt  to  strip 
off  the  whole  placenta  from  the 
surface  of  the  uterus  ?  It  should 
always  be  done,  if  practicable,  without  injuring  the 
substance  of  the  uterus. 


CONSEQUENCES  OF  FAILURE  TO  EXTRACT  IT. 

What  consequences  are  to  be  expected  from  re- 
tention of  part,  or  the  whole  of  the  placenta  ? 
Irritation,  pain,  inflammation  of  the  uterus,  and 
putrefaction  of  the  placenta,  with  the  risk  of  the  con- 
sequences of  absorption  of  pus. 


OF   THE    LYING-IN    CHAMBER.  313 


TREATMENT  OF  THE  CONSEQUENCES. 

How  should  you  treat  the  case  if  putrefaction 
should  occur  ?  By  detergent  washes,  carried  up  into 
the  cavity  of  the  uterus  by  a  suitable  syringe  and 
with  sufficient  force  to  irrigate  it  thoroughly. 

What  kind  of  syringe  should  you  use  ?  One  of  the 
ordinary  kind,  which  can  be  attached  to,  or  inserted 
into  the  end  of  a  gum  elastic  catheter,  or  stomach 
tube,  which  should  be  carefully  introduced  into  the 
cavity  of  the  uterus,  and  the  fluid  then  passed  from 
the  syringe  through  it — or  a  syringe  having  a  long 
curved  pipe,  with  a  bulbous  extremity,  may  be  used 
for  the  same  purpose.  The  force  pump  injection-pipe 
is  the  best  kind  of  apparatus  to  be  used. 

What  kind  of  fluid  should  be  injected  into  the  cavity 
of  the  uterus  ?  That  which  is  bland,  mucilaginous, 
and  detergent,  as  flaxseed  tea,  solution  of  castile 
soap,  &c. 

What  kind  will  be  proper  when  the  exhalations 
from  the  vagina  become  fetid,  in  consequence  of 
decomposition  of  a  part  or  all  the  retained  mass  ? 
They  should  be  of  an  antiseptic  character,  as  lime- 
water  and  camomile  tea,  aromatic  spirits  of  ammonia, 
weak  solution  of  creosote,  chloride  of  lime,  or  soda,  &c. 

What  general  treatment  should  the  patient  receive 
in  cases  of  putrefaction  of  the  retained  placenta  ? 
Care  should  be  taken  to  sustain  her  constitutional 
vigor,  by  a  generous  diet,  and  even  by  stimulants,  if 
she  become  prostrated  under  the  irritative  fever, 
which  may  ensue  from  te  accident. 


27 


314  PHYSIOLOGY   AND    PATHOLOGY 


PHYSIOLOGICAL   AND  PATHOLOaiCAL  CONDI- 
TION OF   FEMALES   DURING   THE   REPRO- 
DUCTIVE PERIOD  OF  LIFE. 

Are  we  to  regard  the  periodical  local  plethora  and 
ordinary  uterine  irritation  or  activity  in  the  female 
after  puberty,  as  a  physiological,  or  a  pathological, 
condition  ?  As  strictly  physiological,  and  pertain- 
ing to  the  maturation  of  a  germ. 

Do  any  of  the  appendages  of  the  uterus  exert  any 
influence  over  the  menstrual  function  ?  The  ovaries 
appear  to  be  indispensable  to  it,  as  upon  their  non- 
existence the  function  does  not  occur,  and  upon  their 
removal  it  becomes  suspended. 

Admitting  that  we  know  very  little  of  the  cause 
of  the  catamenia  or  menses,  what  does  its  regular 
appearance  indicate  ?  A  healthy  condition  of  the 
genital  organs,  and  a  capability  for  procreation  or 
reproduction. 

Are  there  no  exceptions  to  the  rule  that  women 
cannot  conceive  unless  they  have  menstruated  ? 
Some  cases  are  recorded  in  which  women  have  con- 
ceived without  having  menstruated,  but  it  is  supposed 
that  with  them,  conception  took  place  just  before  the 
menstrual  period  would  have  occurred. 

Which  period  is  most  favorable  to  conception, 
before  or  after  menstruation  ?  Immediately  after 
the  secretion  has  taken  place. 

What  opinion  was  formerly  entertained  respecting 
the  quality  of  the  menstrual  fluid  ?  That  it  was 
extremely  noxious  both  to  animal  and  vegetable  sub- 
stances. 

What  is  true  in  reference  to  its  quality  ?  That 
it  possesses  no  noxious  qualities  when  in  a  healthy 
condition. 


OF   THE   HUMAN    FEMALE.  315 

HYGIENIC  RULES  TO  BE  OBSERVED, 

What  rules  of  conduct  should  be  observed  bj  the 
female  during  the  menstruating  portion  of  her  life  ? 
All  those  hygienic  rules  which  are  necessary  to  en- 
sure her  a  good  physical  and  moral  condition. 

What  conditions  of  her  constitution  should  involve 
the  question  of  the  propriety  of  her  marriage  ?  The 
existence  of  scrofula,  rickets,  phthisis,  and  such  trans- 
missible diseases. 

What  precautions  should  be  employed  in  early  life 
to  prevent  the  occurrence  of  such  constitutional  dis- 
orders ?  Every  means  should  be  used  during  child- 
hood to  develop  and  give  tone  to  the  various, tissues 
of  the  system. 

What  must  be  regarded,  in  the  present  habits 
of  society,  as  injurious  to  the  health  of  growing  girls  ? 
The  use  of  ligatures  and  corsets  about  the  body,  in 
dress ;  the  want  of  free  gymnastic  exercises  for  tbe 
development  of  the  skeleton,  and  consequently  of 
the  organs  within  it ;  too  much  constraint  and  con- 
finement of  body  in  one  position  in  the  schools. 

What  is  the  value  of  pedestrian  exercise  in  the 
physical  education  of  young  ladies  ?  All  physical 
exercises,  as  gymnastics,  and  particularly  those  on 
foot,  as  walking,  jumping  rope,  and  dancing  in 
'the  open  air,  contribute  greatly  to  the  establishment 
of  the  health  and  keeping  all  the  secretions  in  proper 
order. 

What  regulations  should  be  enforced  in  regard  to 
diet  ?  The  digestive  organs  should  be  kept  in  order 
by  a  moderate  allowance  of  nutritious  but  not  stimu- 
lating diet,  composed  principally  of  vegetable  and 
farinaceous  substances. 

What  attention  should  be  paid  to  the  condition 
of  the  skin  ?  It  should  be  kept  in  a  soft  and  tran- 
spirable  condition  by  cleanliness,  regular  bowels,  and 
a  proper  amount  of  warm  clothing,  particularly  upon 
the  limbs. 


316  PHYSIOLOGY    AND    PATHOLOGY 

What  amount  of  sleep  is  necessary,  and  when 
should  it  be  obtained  ?  Not  less  than  eight  hours, 
which  should  begin  with  the  early  part  of  the  night. 

What  precautions  are  necessary  with  respect  to 
mental  exercises  or  cerebral  excitement  ?  To  avoid 
both  to  any  considerable  extent,  and  to  discourage 
precocity  of  intellect. 

What  care  should  be  taken  in  reference  to  the  moral 
feelings  ?  They  should  be  regulated,  and  the  passions 
should  not  be  excited  by  reading,  conversation,  or 
other  means. 

DISORDER  OF  THE  MENSTRUAL  FUNCTION, 

What  influence  may  much  excitement  produce  at 
the  time  at  which  the  secretion  ought  to  occur  ? 
Super-excitation  of  the  system  may  so  operate  upon 
the  genital  organs  as  to  prevent  the  occurrence  of  the 
secretion. 

Under  such  circumstances  what  course  should  be 
pursued  ?  The  patient  should  be  subjected  to  re- 
stricted diet,  saline  cathartics,  and  sometimes  even  to 
venesection. 

How  should  we  treat  any  nervous  symptoms  which 
may  occur  in  connection  with  the  menstrual  effort  ? 
It  is  not  often  necessary  to  interfere  much  with  them  : 
mild  anti-spasmodic  remedies,  such  as  spirits  of  nitre, 
camphor  water,  assafoetida,  and  such  articles  may  be 
administered. 

Suppose  the  capillary  circulation  be  feeble,  as  in- 
dicated by  cold  extremities,  soft  feeble  pulse,  &c., 
what  treatment  ought  to  be  adopted  ?  That  which 
would  give  tone  and  vigor  to  the  system,  as  good 
diet,  proper  exercise,  bathing,  pleasant  company,  and 
agreeable  mental  excitement  ;  a  proper  course  of 
tonics,  particularly  mineral  preparations,  may  be  use- 
fully employed. 

AMENORRHCEA. 
What  is  to  be  understood  by  the  phrase,  "  retention 


OF   THE    HUMAN    FEMALE.  317 

of  the   menses?     That   they  have  never  appeared, 
however  old  the  female  may  have  become. 

What  is  meant  by  the  phrase,  "suppression  of. the 
menses?"  That  having  been  once  established,  they 
cease  to  appear  during  some  part  of  the  menstruating 
period  of  female  life. 

What  technical  term  have  we  to  signify  either  of 
these  states  ?     Amenorrhoea. 

Upon  what  causes  may  the  tardy  appearance  of 
the  menses  depend  ?  Defect,  or  absence,  or  want  of 
proper  development  of  the  organs  of  generation,  par- 
ticularly of  the  uterus,  or  ovaries,  or  both,  or  diseases 
of  them. 

Do  defects  of  this  kind  always  interfere  with  the 
health  of  the  patient  so  circumstanced  ?  It  some- 
times happens  that  women  so  circumstanced  enjoy 
good  health. 

Why  is  a  knowledge  of  this  fact  important  ?  That 
females  may  not  be  subject  to  the  powerful  action  of 
medicines  supposed  to  be  emmenagogues  or  specifics 
for  producing  the  menses. 

What  proofs  have  we  of  the  evil  consequences  of 
attempting  to  force  the  menstrual  secretion  in  some 
of  these  cases  of  tardy  appearance  ?  Many  in- 
stances on  record,  in  which  upon  dissection,  organs 
were  absent  or  but  very  partially  developed,  and  one 
particularly  seen  by  Dr.  Hodge,  in  which  after  long 
and  ineffectual  treatment  by  emmenagogues,  cathar- 
tics, and  serious  injury  to  general  health ;  the  profes- 
sor in  consultation,  examined  the  patient  but  could 
find  no  uterus. 

Under  what  plan  of  treatment  did  this  case  improve  ? 
A  general  invigorating  course,  including  proper  exer- 
cise in  the  open  air. 

Under  what  other  circumstances  may  emansio  men- 
sium,  or  retention  of  the  menses  occur  ?  ,  When  the 
health  is  bad,  and  the  organs  partially  developed,  and 
again  when  the  health  is  bad  and  all  the  organs  appa- 
rently developed. 

27* 


318  PHYSIOLOGY   AND    PATHOLOGY 

What  is  the  opinion  of  some  experienced  teachers 
respecting  the  popular  notion  that  the  retention  of 
the^menses  is  the  cause  of  the  ill  health  ?  That  it  is 
the  contrary  of  what  is  true,  and  that  the  ill  health  is 
the  cause  of  the  retention  in  those  cases  in  which  the 
organs  were  properly  developed. 

Upon  what  may  this  ill  health  depend?  Upon 
a  bad  diathesis,  as  phthisis,  scrofula,  &c. ;  impro- 
prieties in  living,  neglect  of  the  means  of  proper 
general  physical  development,  errors  in  the  physical 
education,  causing  the  female  to  remain  a  child  until 
a  late  period  of  her  life. 

What  condition  of  the  nervous  system,  is  often 
an  accompaniment  of  amenorrhoea  ?  Neuralgia,  hys- 
teria, &c. 

Is  it  probable  that  the  uterus  ever  becomes  the 
seat  of  a  congestion  and  irritation  ?  It  probably 
does  so,  in  some  cases,  and  it  then  appears  as  though 
the  system  was  above  the  secreting  point. 

What  inconveniences  might  arise  from  stimulating 
treatment  in  such  cases  ?  It  might  bring  on  serious 
consequences,  as  congestion,  apoplexy,  &c. 

What  then  should  be  done  ?  Diminish  cerebral 
irritation  by  depletion,  by  cooling  saline  laxatives, 
antimonials,  &c. 

What  would  be  proper  after  this  had  been  eifected  ? 
Seeking  to  restore  the  secretions  by  warm-bath,  hip- 
bath, warm  injections,  &c.  Allowing  the  patient 
demulcent  drinks,  as  weak  pennyroyal  tea,  &c. 

Do  purgatives  interfere  with  the  performance  of  this 
secretion  ?  They  do  not,  as  has  been  supposed  by  some. 

VARIETIES  OF    AMENORRHCEA. 

Into  how  many  varieties  is  suppression  of  the 
menses  divided  ?     Into  two — acute  and  chronic. 

How  do  ^^e  distinguish  acute  suppression  ?  By  the 
action  of  its  cause  during  the  flow. 

How  does  the  cause  operate  in  .chronic  suppres- 
sion ?     During  the  interval  of  the  secretion. 


OF   THE   HUMAN   FEMALE.  319 

Which  is  the  severer  form  of  suppression  ?  That 
in  which  the  cause  acts  and  arrests  the  secretion 
during  its  flow. 

What  class  of  females  is  most  liable  to  suffer  from 
this  suppression  ?  Those  of  irritable  constitutions  or 
temperaments. 

What  may  be  regarded  as  predisposing  causes  of 
suppression  ?     Irritability  of  the  system. 

What  are  some  of  the  actual  causes  of  affection  ? 
Certain  moral  influences,  violent  passions  of'  the 
mind,  frights  from  falls,  sudden  bad  news,  terror, 
dread,  rumors  of  wars,  sudden  transitions  of  tempera- 
ture, &c. 

How  far  may  physical  causes  operate  in  this  re- 
spect ?  The  sudden  application  of  cold  to  the  exter- 
nal surface — violent  diseases,  fever,  inflammatory 
affections,  irritation  of  powerful  medicines,  stimu- 
lating drastic  cathartics, — all  may  act  in  the  produc- 
tion of  the  suppression  of  the  catamenia. 

How  does  sudden  suppression  affect  the  system  ? 
The  effect  of  sudden  suppression,  or  that  of  the 
cause  producing  sudden  .suppression,  is  often  very  se- 
vere, and  greatly  disturbs  the  system  which  is  most 
predominant  in  the  individual,  producing  hystei'ic  con- 
vulsions, &c.,  in  the  nervous ;  apoplexy  in  the  vascular, 
or  sanguineous  temperament;  attacks  of  gout,  if  the 
patient  have  a  gouty  diathesis,  &c.  In  some  cases,  se- 
vere uterine  neuralgia  is  induced  by  this  check  of 
the  secretory  action. 

TREATMENT  OF  AMENORRH(EA. 

What  are  the  indications  for  treatment  ?  They 
must  be  founded  on  the  temperament  and  diathesis  of 
the  patient.  The  indication  is  always  to  diminish  the 
secondary  irritation,  and  correct  that  condition  of  the 
system  which  interferes  with  the  proper  action  of  the 
uterus.  Thus  we  are  to  clear  the  primae  viae  by  vomit- 
ing and  purging,  if  obstructed,  then  commence  with 
the  mildest  anti-spasmodic  medicines,  as  ether,  assa- 


320  PHYSIOLOGY   AND    I'ATIIOLOGY 

foetida,  camphor,  hyosciamus,  if  tlie  nevous  system  be 
much  disturbed. 

Under  what  circumstances  may  vascular  depletion  be 
required  ?  When  there  is  much  plethora,  or  vascular 
excitement,  the  lancet  should  be  used :  if  there  be 
local  pains  without  general  vascular  disturbance,  cups 
or  leeches  should  be  applied  to  the  part  aiFected. 

Which  should  be  resorted  to  first,  vascular  deple- 
tion or  anti-spasmodics  ?  .  In  cases  of  vascular  excite- 
ment, anti-spasmodics  are  of  little  avail,  unless  pre- 
ceded by  loss  of  blood,  cathartics,  or  nauseants, 
sufhcient  to  reduce  the  circulation. 

When  is  the  use  of  opium  indicated  ?  Only  when 
the  course  just  proposed  has  been  tried,  and  other 
anti-spasmodics  have  failed  to  quiet  the  system. 

What  is  the  best  revulsive  treatment  in  cases  of  sud- 
den suppression  ?  -  Plot  pediluvia,  long  continued,  and 
rendered  stimulating  by  some  spices,  as  mustard, 
ginger,  &c. 

What  is  probably  one  of  the  very  best  remedies  we 
possess  for  this  state  of  things  ?  Copious  enemata  of 
warm  water. 

What  should  be  done  conjointly  with  the  use  of  enema- 
ta ?  Place  the  patient  in  bed  and  give  her  warm  drinks, 
as  mint  tea,  pennyroyal  tea,  &c.  to  bring  on  perspiration. 

Suppose,  however,  she  be  febrile  ?  Then  the  stimu- 
lating drinks  would  be  improper,  till'  she  had  been 
purged  and  perhaps  bled. 

What  should  we  hope  to  gain  from  the  application 
of  warm  poultices  to  the  vulva  ?  They  are  useful,  and 
sometimes  preferable  to  the  custom  of  sitting  the  pa- 
tient over  the  vapor  of  hot  water,  for  the  promotion 
of  secretion  from  the  uterus. 

When  might  leeches  be  applied  to  the  genital  or- 
gans ?  Whenever  there  appears  to  be  a  fulness  of  the 
uterine  vessels,  and  the  secretion  does  not  return  to 
their  relief. 

Where  should  they  be  applied  ?  To  the  pudendum, 
to  the  vagina,  or  to  the  os  uteri  itself. 


OF   THE   HUMAN    FEMALE.  321 

How  gliould  the  leeches  be  applied  to  the  os  and 
cervix  uteri?  Bjdneans  of  a  speculum,  or  proper 
tubes  capable  of  embracing  the  os  uteri  and  sustaining 
other  parts. 

When  the  system  shall  have  been  brought  to  its 
proper  standard  by  the  means  already  proposed,  and 
the  catamenia  do  not  still  appear,  what  additional 
means  should  be  used  ?  This  would  be  the  proper 
time  for  the  administration  of  emmenagogues  so 
called,  as  aloes,  madder,  senna,  hellebore,  Spanish 
flies,  &c. 

Upon  what  cause  does  chronic  amenorrhoea  depend  ? 
Mostly  upon  bad  condition  of  the  general  health,  ow- 
ing perhaps  to  serious  disease  in  some  organs,  as 
phthisis,  hepatitis,  &c. 

In  this  case,  to  what  part  of  the  system  should  our 
remedies  be  addressed  ?  To  that  affected — if  the  pul- 
monary organs,  to  the  lungs,  if  the  hepatic  system,  -to 
the  liver,  &c. 

What  train  of  functional  disturbance  mostly  accom- 
panies chronic  amenorrhoea  ?  Spinal  irritation,  ce- 
rebral congestion,  and  irregularities  of  the  digestive 
apparatus. 

What  kind  of  secretion  sometimes  affords  a  partial 
substitute  for  the  true  menstruation  ?  Leucorrhoea,  mu- 
cous or  muco-serous  discharges  from  the  uterus  or 
vagina,  or  from  both. 

What  is  the  proper  treatment  for  chronic  amenorr- 
hoea ?  That  which  improves  the  general  health,  as 
alteratives,  general  tonics,  and  those  aperients  which 
act  particularly  on  the  lower  bowels. 

In  what  way  do  the  so  called  emmenagogue  medi- 
cines usually  act  ?  Some  act  generally  upon  the  con- 
stitution— some  more  locally  upon  the  lower  bowels — • 
some  upon  the  bladder,  and  a  very  few  directly  upon 
the  uterus  itself. 

With  what  organs  doiss  the  uterus  appear  to  have  a 
directly  sympathetic  connection  ?     With  the  mammae. 

What  advantage  does  this  knowledge   afford  us  in 


322  PHYSIOLOGY   AND    PATHOLOGY 

the  treatment  of  amenorrhoea  ?  That  by  stiinulating 
the  mammae,  we  have  sometimes  excited  the  secretory 
action  of  the  uterus. 

What  direct  applications  have  been  made  to  the 
uterus  with  benefit  ?  Injections  per  vaginam,  of  ten 
or  more  drops  of  acetate  of  ammonia  to  one  ounce  of 
milk. 

What  means  have  been  thought  useful  in  promoting 
the  menstrual  secretion,  by  acting  directly  upon  the 
nervous  system?     Electricity  and  galvanism. 

What  is  to  be  said  of  the  effect  of  physical  excite- 
ment of  the  organ  by  matrimony  ?  It  may  be 
adapted  to  a  few  particular  cases,  but  is  often  at- 
tended by  an  aggravation  of  the  condition  of  the 
uterus,  sometimes  inducing  permanent  disease  in  it. 

What  are  probably  the  very  best  general  reme- 
dies operating  on  the  bowels  we  can  use  in  amenorr- 
hoea?    Rhubarb  and  aloes  in  combination. 

What  substances  have  been  thought  useful  by  acting 
on  the  kidneys  or  bladder  ?  The  spirits  of  turpentine, 
the  copaiba,  and  various  other  balsamic  preparations. 
The  tincture  of  cantharides  has  been  regarded  as  use- 
ful by  many. 

What  other  articles  of  the  materia  medica  are  sup- 
posed to  have  a  sort  of  specific  action  upon  the  uterus  ? 
Madder,  guaiacum,  savin,  iodine,  strichnine,  and  black 
hellebore. 

In  what  doses  should  the  savin  and  the  black  helle- 
bore be  administered  ?  Half  a  grain  of  the  extract, 
or  from  five  to  ten  grains  of  the  powder  of  savin — 
of  the  tincture  of  hellebore  from  ten  or  twelve  drops 
to  a  teaspoonful,  two  or  three  times  a  day,  one  or  two 
weeks  before  the  expected  time. 

Can  either  of  these  powerful  remedies  be  used  in 
any  or  every  condition  of  the  system  ?  They  all  re- 
quire caution.  The  system  should  be  properly  pre- 
pared for  the  action  of  either  of  them,  by  bleeding, 
purging,  &c.,  whenever  there  is  a  plethoric  or  an  in- 
flammatory diathesis. 


OF   THE    HUMAN    FEMALE.  828 

What  plan  of  treatment  may  be  continued  through 
the  whole  time,  without  regard  to  periods  ?  The  hy- 
driodate  or  other  preparations  of  iron,  madder,  spirits 
of  turpentine,  and  tincture  of  cantharides. 

RETENTION  FROM  PHYSICAL  CAUSES. 

By  what  causes  may  the  menses  be  retained,  when 
the  organs  are  well  developed,  and  the  health  of  the 
female  good  ?  By  absence  of  the  vagina,  occlusion  of 
the  OS  tincse,  closure  of  the  hymen,  vulva,  or  some  such 
mechanical  obstacle  to  its  escape. 

What  occurs  in  such  cases  ?  The  secretion  goes 
on,  but  the  fluid  is  accumulated,  because  it  has  no 
outlet. 

What  consequences  result  from  this  obstruction  ? 
In  time,  the  abdomen  swells,  the  condition  of  the  pa- 
tient excites  suspicion  of  pregnancy,  dropsy,  or  the 
formation  of  a  tumor,  and  the  opinion  of  a  physician 
is  appealed  to. 

DUTY  OF  THE  PHYSICIAN  IN  SUCH  CASES. 

What  course  should  he  pursue  ?  First,  make  a 
careful  inquiry  into  the  history  of  the  case,  then  make 
a  proper  physical  examination  of  the  parts. 

What  may  he  expect  to  find  in  case  the  occlusion 
exists  in  the  hymen  ?  Distension  of  the  part,  the 
membrane  of  a  dark  blue  color,  with  a  sense  of  fluc- 
tuation. 

What  may  he  expect  to  find  in  case  the  atresia  ex- 
ists in  the  orifice  of  the  uterus  ?  If  at  the  os  tincae, 
he  may  find  a  tumor  like  the  extremity  of  an  ellipse, 
projecting  into  the  vagina,  and  fluctuating  under  the 
touch.  If  at  the  internal  os-uteri,  the  neck  and  ex- 
ternal os-uteri  may  be  but  little  changed  from  natural, 
but  the  body  may  be  found  expanded  out  into  a  sort 
of  globular  tumor,  somehat  compressible  to  the  touch. 

What  becomes  of  this  aflection,  if  not  relieved  by 
an  operation  ?  Sooner  or  later  an  opening  is  formed, 
and  the  fluid  escapes. 


324  PHYSIOLOGY   AND    PATHOLOGY 

What  is  the  direction  of  the  opening  ?  It  is  va- 
rious ;  sometimes  in  the  rectum,  and  sometimes  into 
other  parts. 

If  the  hymen  be  entire,  what  kind  of  an  opening 
should  be  made  into  it  ?     Crucial,  or  stellated. 

Suppose  the  vagina  to  be  absent,  what  risk  would 
there  be  in  attempting  an  incision  for  the  escape  of 
the  accumulated  fluid  ?  It  would  be  dangerous  to  at- 
tempt operation  for  the  exit  of  the  retained  menses 
unless  it  were  performed  by  one  possessed  of  great 
anatomical  and  surgical  attainments. 

When  the  obstruction  exists  in  the  uterus  itself, 
what  plan  should  be  adopted  ?  Attempts  should  be 
made  gradually  to  dilate  the  orifice  by  a  series  of 
bougies. 

Is  this  an  operation  easy  to  be  accomplished?  It  is 
often  extremely  difficult. 

What  is  the  true  method  of  doing  it  ?  Pull  the  os 
tincae  forward  by  a  finger  in  the  vagina,  or  anus,  and 
keep  it  pressed  towards  the  pubis,  to  make  the  neck 
of  the  uterus  have  the  same  axis  as  the  inferior  strait, 
and  then  cautiously  pass  the  bougie. 

CHLOROSIS. 

To  what  condition  of  the  system  is  the  term  chlorosis 
applied  ?  To  that,  in  which  about  the  menstruating 
period  of  life,  there  is  great  pallor  of  the  skin,  and 
torpor  of  all  the  functions  of  the  system. 

What  does  this  state  of  the  system  indicate  ?  An 
impairment  or  defect  of  the  vis  vit{?e,  a  general  func- 
tional derangement. 

Why  is  it  called  chlorosis  ?  Because  persons  af- 
fected with  it,  are  vulgarly  said  to  have  green  or  fall- 
ing sickness. 

How  does  it  generally  begin  to  develope  itself?  By 
a  desire  to  eat  outre  articles  ;  as  dirt,  slate  pencils,  re- 
cently quenched  coals,  &c. 

What  is  the  condition  of  the   alimentary  canal  in 


OF   THE    HUMAN    FEMALE.  325 

such  cases  ?  Torpid  throughout ;  digestion  slow,  bowels 
constipated,  stools  clay  colored. 

What  is  the  probable  cause  of  the  pallid,  or  pale 
yellow  or  greenish  color  of  the  skin  ?  The  extreme 
torpor  of  the  liver. 

How  is  chlorosis  to  be  distinguished  from  icterus  ? 
By  the  w^ant  of  the  yellow  deposit  in  the  adnata  of 
the  eyes. 

What  is  the  condition  of  the  cerebral  and  vascular 
systems  in  chlorosis  ?  The  intellect  is  very  torpid, 
and  the  pulse  soft  and  without  force. 

How  is  the  nervous  system  affected  ?  The  nerves 
of  sensation  and  motion,  are  sometimes  greatly  dis- 
turbed, hence  hysteria,  and  neuralgic  pains. 

What  is  at  present  to  be  said,  respecting  the  plans 
often  adopted  for  the  treatment  of  this  affection  ?  The 
practice  is  very  often  erroneous,  especially  when  the 
neuralgic  pains  in  the  side  have  been  mistaken  and 
treated  for  pleurisy  or  inflammation. 

What  reasons  may  practitioners  have  had  for  diag- 
nosticating inflammatory  diseases  and  resorting  to  de- 
pletion in  these  cases  ?  Probably,  that  in  conjunction 
with  the  pain,  there  is  sometimes  palpitation  and  fe- 
brile excitement. 

What  are  the  consequences  of  the  case  becoming 
chronic  ?  They  are  often  serious  and  difficult  of 
cure. 

What  is  the  usual  condition  of  the  organs  under 
such  circumstances  ?  They  are  sometimes  found  dis- 
eased and  altered,  but  most  frequently  they  are  in  an 
anemic  condition. 

What  are  the  results  of  this  disease  ?  Some  patients 
recover  and  get  entirely  well;  while  others  become 
affected  with  dropsy,  &c. 

Does  the  uterus  ever  perform  its  functions  during 
this  chlorotic  state  ?  Some  patients  have  a  slight, 
serous  menstruation — sometimes  it  even  contains  red 
particles. 

What  conditions  of  life  are  most  favorable  to  the 
28 


1126  PHYSIOLOGY    AND    PATHOLOGY 

occurrence  of  clilorosis  ?  All  densely  populated 
places,  where  there  is  a  deficiency  of  good  air  and  ex- 
ercise, and  hence  especially  in  the  large  manufactur- 
ing towns  of  Europe,  and  even  in  this  country  where 
girls  are  sent  too  early  and  confined  too  closely  to 
school. 

TREATMENT  OF  CHLOROSIS. 

What  are  the  true  indications  for  treatment  in  cases 
of  chlorosis?  To  give  strength  to  the  system  by 
restoring  the  healthy  condition  of  the  digestive  appa- 
ratus. 

What  is  to  be  done  to  the  reproductive  organs,  at 
this  time  ?  No  especial  attention  is  to  be  given  to 
them,  until  the  constitution  is  improved. 

What  regard  should  be  had  to  the  full  development 
of  all  the  organs  in  the  body  ?  This  is  most  impor- 
tant, and  every  proper  means  should  be  availed  of  for 
this  purpose. 

What  kind  of  medicine  should  be  used  ?  Such  |1- 
teratives  as  moderately  increase  the  action  of  the  mu- 
cous membranes. 

If  calomel  be  employed,  in  what  way  ought  it  to  be 
administered  ?  In  doses  of  from  one  eighth  to  half 
of  a  grain,  and  cautiously  repeated. 

What  regard  should  we  have  for  the  powers  of  di- 
gestion during  this  course  of  medicines  ?  Carefully 
avoid  impairing  the  function  of  digestion,  but  rather 
stimulating  it. 

Is  it  proper  to  use  any  additional  alteratives  ?  The 
preparations  of  sarsaparilla  are  appropriate  in  some  of 
these  c^ses  in  conjunction  with  the  calomel,  or  blue  pill. 

Why  is  iodine,  or  some  of  its  preparations  indi- 
cated ?  Because,  in  proper  doses  they  stimulate  the 
organs  of  digestion. 

What  influence  do  the  mucous  secretions  exert,  if 
left  within  the  cavities  in  which  they  were  formed  ? 
They  irritate  the  system  and  disturb  the  digestive 
function. 


OF   THE    HUMAN   FEMALE.  327 

How  then  ought  they  to  be  disposed  of?  They 
should  be  carried  off  by  proper  laxative,  or  aperient 
medicines. 

What  may  be  regarded  as  the  best  medicines  for 
this  purpose  ?     Rhubarb,  aloes,  senna,  castor  oil,  &c. 

Under  what  circumstances  would  moderately  stimu- 
lating, or  cordial,  bitter  tinctures,  become  useful  ? 
When  there  is  a  sluggish,  or  cold  state  of  the  sys- 
tem. 

What  course  should  be  adopted,  when  the  alterative 
and  aperient  plan  have  been  carried  into  effect  ?  The 
patient  should  be  put  upon  the  use  of  tonics ;  as  in- 
fusions of  camomile,  or  wild  cherry  bark ;  or  the  pre- 
paration of  iron  :  as  the  oxide,  the  sulphate,  and  the 
iodide  of  iron,  or  the  pure  metallic  iron. 

Is  it  reasonable  to  expect  the  catamenia  to  appear 
before,  or  after  the  restoration  of  health  ?  Not  until 
after  the  health  has  improved. 

DYSMENORK-HCEA. 

What  is  meant  by  the  term  dysmenorrhcea  ?  Se- 
vere pain  during  the  act  of  menstruation. 

How  is  the  secretion  in  regard  to  amount  and  fre- 
quency ?  It  may  be,  and  generally  is,  regular  in  re- 
gard to  its  return,  but  the  quantity  secreted  is  usu- 
ally less,  though  some  think  it  is  rather  greater  in 
some  instances. 

What  opinions  exist  in  reference  to  the  cause  ? 
Some  say  the  difficulty  exists  in  the  secretion  of  the 
fluid,  others  that  it  is  owing  to  an  obstruction,  or 
difficult  excretion  of  the  fluid  after  it  has  been  secreted. 

What  temperaments  seem  to  be  most  liable  to  it  ? 
Nervo-sanguine  temperaments. 

At  what  age  of  menstrual  life  does  it  occur  ?  Wo- 
men are  subject  to  have  it  occur  at  any  portion  of 
their  menstrual  life. 

What  is  the  usual  condition  of  health  in  the  inter- 
vals ?  Good  : — if  impaired,  it  mostly  is  so  from  some 
other  cause. 


328  PHYSIOLOGY    AND    PATHOLOGY 


SYMPTOMS   OF  DYSMENORRHCEA. 

What  are  the  symptoms  of  dysmenorrhoea  ?  A 
sense  of  coldness,  nervousness,  &c.  Pain  in  the  upper 
part  of  the  sacral  region,  thence  round  the  ilia,  or 
through  to  the  hypogastrium — sense  of  fulness  and 
bearing  down  in  the  pelvic  region. 

Are  these  feelings  constant  or  paroxysmal  ?  They 
occur  in  paroxysms,  like  labor  pains ;  indeed  in  some 
cases  it  is  difficult  to  distinguish  them  from  efforts  at 
abortion. 

What  sympathetic  disorders  arise  from,  or  accom- 
pany the  paroxysms  of  dysmenorrhoea  ?  Flatulence, 
constipation,  vomiting,  bilious  nervous  headache,  pal- 
pitation, throbbing,  &c. ;  sense  of  fulness  and  actual 
congestion  in  the  lower  part  of  the  abdomen. 

What  is  the  usual  duration  of  one  of  these  parox- 
ysms ?  Sometimes  this  severe  suffering  continues  for 
a  day  or  two,  when  the  secretion  appears  and  the  pa- 
tient becomes  easier. 

What  is  noticed  as  peculiar  in  the  discharge  in  some 
cases  ?  That  it  is  membranous,  and  thrown  off  in 
shreds,  or  in  an  entire  sac  resembling  the  shape  of  the 
internal  surface  of  the  uterus. 

What  is  probably  the  exact  character  of  this  mass  ? 
Opinions  appear  to  be  various.  Some  think  it  a  co- 
agulation of  blood,  and  not  the  lymph  of  inflamma- 
tion, as  that  formed  in  cases  of  croup. 

What  is  the  probable  cause  of  the  pain,  if  the  idea 
of  a  mere  coagulation  of  secretion  be  correct  ?  The 
pain  would  then  seem  to  depend  upon  the  severe  con- 
tractions of  the  uterus  to  expel  the  coagulum,  &c. 

What  influence  does  this  condition  of  the  secretory 
function  of  the  uterus  appear  to  have  upon  the  general 
health  ?  Very  often  the  health  of  the  patient  in  the 
interval  remains  good,  though  the  disease  has  con- 
tinued to  return  with  unabated  severity  from  one  to 
twenty  years.     It   is  however   true,  that   the   health 


OF    THE    HUMAN    FEMALE.  329 

may  become  impaired  in  some  cases,  during  the  exist- 
ence of  dysmenorrhoeal  state. 

What  is  the  condition  of  the  mouth  and  neck  of  the 
uterus  in  the  female  affected  with  dysmenorrhoea  ? 
In  general  the  neck  is  tumid  and  the  mouth  a  little 
open. 

What  is  known  respecting  the  capability  for  con- 
ception, in  females  affected  with  dysmenorrhoea  ? 
As  a  general  rule,  females  so  affected  do  not  con- 
ceive— but  numerous  exceptions  to  the  rule  exist. 

CAUSES  OF  DYSMENORRH(EA. 

What  are  the  general  predisposing  causes  of  this 
disease  ?  Temperament,  particularly  that  of  the 
nervo-sanguine. 

What  may  be  regarded  as  occasional  causes  of  this 
disease  ?  Cold,  violent  mental  emotions,  fright,  &c. 
It  has  been  brought  on  by  matrimony — it  is  some- 
times the  result  of  metastasis  of  cutaneous  or  neural- 
gic disorders,  or  of  gastric  affections. 

What  agency  may  displacements  of  the  uterus  exert 
in  the  production  of  dysmenorrhoea  ?  It  is  very  lia- 
ble to  follow  any  displacement  of  the  uterus. 

What  may  be  considered  as  mechanical  causes  of 
dysmenorrhoea  ?  Besides  the  various  displacements  of 
the  uterus  which  may  be  regarded  to  some  extent  de- 
cidedly mechanical,  causes  are  occasionally  found  in 
obstructions  of  the  internal  and  external  os  uteri,  and 
also  in  the  canal  of  the  cervix  uteri. 

What  may  be  said  of  the  severity  of  the  pain  in 
some  ,cases  of  dysmenorrhoea  ?  That  it  is  greater 
than  that  of  labor. 

What  idea  is  entertained  respecting  the  inflamma- 
tory or  neuralgic  character  of  this  affection  ?  Some 
think  it  neuralgic  or  spasmodic,  which  is  often  true — 
others  regard  it  as  inflammatory.  By  some  good  au- 
thority it  is  thought  that  it  most  probably  depends 
upon  excitement  of  the  vascular  system,  upon  a  con- 
gestion not  amounting  to  actual  inflammation.  In 
28* 


330  PHYSIOLOGY   AND    PATHOLOGY 

other  words,  an  exaltation  of  vitality — a  nervous 
excitement  with  vascular  congestion.  Some  practi- 
tioners, as  Dr.  Dewees,  thought  it  depended  upon 
low  or  depressed  action. 

TREATMNT  OF  DYSMENORRHCEA. 

How  is  the  treatment  of  this  affection  to  he  di- 
vided ?  Into  that  which  is  to  be  applied  during  the 
paroxysms,  and  that  to  be  used  in  the  interval. 

What  should  first  be  resorted  to  in  the  paroxysm? 
A  free  bleeding  to  the  amount  of  thirty  or  forty 
ounces — next,  cups  to  the  sacrum,  or  leeches  to  the 
vulva,  groin,  or  the  uterus  itself — then  enemata  of  warm 
mucilages,  and  as  soon  as  the  vascular  excitement 
has  been  allayed,  the  warm  hip  bath  should  be  em- 
ployed. 

When  may  narcotics  be  resorted  to  ?  As  soon  as 
vascular  excitement  is  allayed,  anodyne  enemata  may 
be  used  with  advantage. 

What  anodynes  are  best  in  this  case  ?  Dewees 
recommended  camphor  enemata,  and  Parrish  found 
marked  benefit  from  directing  patients  to  take  four 
grains  of  camphor,  three  times  a  day,  two  or  three 
days  before  the  time  of  the  paroxysm.  The  Dover's 
powder  is  also  useful  in  allaying  pain  and  exciting  the 
action  of  the  skin.  Other  narcotics,  as  hyosciamus, 
&c.,  are  sometimes  beneficial. 

What  other  article  has  been  thought  useful  in 
diminishing  the  severity  of  the  attack  ?  The  acetate 
of  ammonia. 

What  should  be  done  in  the  interval  to  prevent  the 
return  of  the  paroxysm  ?  Endeavor  to  ascertain  the 
cause  of  the  dysmenorrhoea,  and  if  possible  remove  it. 
Thus  if  the  patient  have  displacement  of  the  uterus,  it 
must  be  corrected.  The  same  may  be  said  of  the 
digestive  organs,  which  should  be  restored  if  out  of 
health,  by  proper  exercise,  alteratives,  tonics,  and 
laxatives. 


OF   THE    HUMAN    FEMALE.  381 

Are  patients  ever  benefited  by  rest  ?  It  has  been 
thought  useful  in  some  cases. 

What  may  be  said  of  cold  bathing  ?  It  is  useful 
in  the  intervals  to  keep  down  any  inordinate  vascular 
excitement. 

Can  every  patient  bear  the  action  of  cold  bathing  ? 
Not  every  one,  and  hence  it  must  be  tried  cautiously. 
To  those  whom  it  suits  it  is  very  useful. 

What  internal  remedies  have  been  proposed  in  the 
interval  as  useful  in  the  prevention  of  the  return^  of 
the  paroxysms  ?  Sulphuric  acid,  sulphate  of  zinc, 
preparations  of  senega,  volatile  tincture  of  guaia- 
cum,  &c. 

What  can  be  said  of  the  efficacy  of  the  last  article, 
so  highly  recommended  by  Dr.  Dewees  ?  Experrience 
has  taught  that  it  is  not  useful  in  all  cases. 

What  should  be  the  immediate  object  of  the  treat- 
ment just  before  the  expected  paroxysm  ?  To  relax 
the  system  and  prevent  spasm  by  using  the  warm 
bath — by  retiring  early  to  bed — by  opening  the 
bowels — by  large  warm  mucilaginous  enemata — by 
the  use  of  warm  injections  into  the  vagina — warm 
cataplasms  to  pudendum,  and  by  a  moderate  use  of 
anodynes. 

What  is  the  proper  treatment  of  mechanical  dys- 
menorrhoea  ?  Some  practitioners  are  in  the  habit  of 
dilating  the  constricted  portion  of  the  mouth  or  neck 
by  bougies  of  different  sizes. 

Can  this  plan  be  relied  upon  as  effectual  ?  It  has 
not  succeeded  in  all  cases,  though  it  generally  miti- 
gates the  suffering. 

MENORRHAGIA. 

What  are  we  to  understand  by  the  term  menorrha- 
gia  ?  An  increased  or  excessive  secretion  of  the 
menses. 

Are  we  to  receive  this  t§rm  in  a  positive  or  relative 
sense  ?  Menorrhagia  is  a  relative  term,  as  different 
persons  differ  so  much  in  regard  to  the  amount,  and 


332  PHYSIOLOGY   AND    PATHOLOGY 

the  same  person  may  be  so  diiferent  at  different 
times  in  this  respect,  that  it  is  to  be  considered  as  a 
menorrhagia,  only  when  it  is  productive  of  bad  conse- 
quences. 

What  is  the  pathology  of  menorrhagia  ?  It  is  evi- 
dently in  some  cases  the  result  of  an  inflammatory 
action,  but  in  many  females  it  is  accompanied  by  a 
feeble  state  of  the  system. 

What  period  of  life  is  most  incident  to  it  ?  It 
most  commonly  occurs  at  the  latter  part  of  menstrual 
life,  though  some  young  women  are  subject  to  it. 

CAUSES  OF  MENORRHAGIA. 

What  are  some  of  its  causes?  Nervous  excite- 
ment, vascular  excitement,  fevers,  &c.,  cold  checking 
perspiration,  causing  internal  congestions,  &c. 

By  what  is  it  aggravated  ?  By  some  diseases  and 
displacements  of  the  uterus,  as  anteversion,  retrover- 
sion, &c. 

With  what  is  menorrhagia  easy  to  be  confounded  ? 
With  hemorrhage  from  the  uterus,  caused  by  polypi, 
ulcers,  cauliflower  excrescences,  &c. 

What  are  the  only  positive  means  of  discrimin- 
ation in  such  cases  ?     Careful  physical  examination. 

With  what  other  aff'ection  may  menorrhagia  be  con- 
founded ?  Abortion  and  its  attendant  hemorrhage 
and  lochia. 

TREATMENT   OF   MENORRHAGIA. 

Upon  what  should  the  treatment  be  founded?  As 
accurate  a  knowledge  as  possible  of  the  cause. 

What  kind  of  treatment  is  mostly  indicated  ?  An 
antiphlogistic  treatment,  sometimes  involving  san- 
guineous depletion — then  revulsives  to  the  lower  ex- 
tremities, by  dry  warm  feet,  blisters,  setons,  and  sti- 
mulating liniments,  &c.,  but  occasionally  the  patient 
requires  tonics. 

What  internal  remedies  should  be  given  ?  The 
saline  laxatives,   saline  mixture,    digitalis,    &c.,   and 


OF   THE    HUMAN   FEMALE.  333 

when  the  excitement  is  alkyed,  small  doses  of  ergot 
should  be  administered. 

What  treatment  seems  peculiarly  proper  in  the 
intervals  ?  The  application  of  cold,  moderate  at  first, 
but  gradually  increasing  in  intensity,  as  the  cold  bath, 
cold  douches,  &c. 

Upon  what  do  the  irritative  forms  of  monorrhagia 
depend  ?  Upon  an  irritable  condition  of  the  uterus, 
perhaps  the  result  of  over  excitement  of  the  organ. 

Towards  what  point  should  our  attention  be  parti- 
cularly directed  in  such  cases  ?  The  condition  of  the 
uterus.    ■ 

What  is  the  result  to  the  patient,  from  protracted 
monorrhagia,  arising  from  any  of  the  several  causes  ? 
Extreme  debility,  anemia,  dropsy,  and  sometimes  com- 
pletely broken  health. 

Which  should  claim  our  attention  most,  the  consti- 
tution or  the  discharge  ?  Gooch,  says  in  this  case, 
take  care  of  the  discharge ;  but  Hodge,  says  very 
properly,  take  care  of  both.  Remove  all  aggravating 
causes ;  thus,  if  displacements  exist,  rectify  them, 
abstain  from  all  sexual  excitements,  and  take  care  to 
improve  the  tone  of  the  system,  support  patient  with 
animal  food,  &c.,  clothe  her  warmly,  particularly 
about  the  feet,  give  her  a  proper  allowance  of  wine, 
make  use  of  rough  frictions  and  other  revulsive  re- 
medies, as  dry  cups,  rubefacients,  and  particularly 
blisters. 

What  internal  remedies  may  be  administered,  as 
astringents,  to  check  the  discharge  ?  The  sugar  of 
lead,  or  the  sulphate  of  zinc  ;  one  of  the  best  prepara- 
tions, is  probably  rhatany.  Monesia,  and  infusion 
of  red  roses  have  been  recommended,  so  also,  have 
small  doses  of  ergot,  say  four  or  five  grains,  four  or 
five  times  a  day. 

LEUCORRH(EA. 

Are  females  liable  to  any  other  affections  during 
the  menstrual  life,  which  seem  to  depend  upon  it? 


334  PHYSIOLOGY   AND    PATHOLOGY 

They  are,  particularly  to  %  white  secretion  from  the 
uterus  and  vagina,  sometimes  from  both. 

What  is  this  white  secretion  called  ?  Fluor-albus, 
or  leucorrhoea,  or  vulgarly  "  whites." 

CAUSES  OF   LEUCORRIKEA. 

Upon  what  does  this  secretion  appear  to  depend  ? 
The  application  of  specific  virus,  as  that  of  gonor- 
rhoea ;  the  presence  of  some  irritating  body,  as  po- 
lypus, and  other  tumors  ;  and  it  may  arise  from  any 
of  the  ordinary  causes  of  inflammations.  By  some, 
indeed,  it  is  regarded  as  uterine  catarrh. 

DIFFICULTIES  OF   DIAGNOSIS. 

What  difficulties  are  there  in  the  way  of  correct 
diagnosis  ?  Perhaps,  principally,  the  ignorance  of 
physicians,  growing  out  of  the  reluctance  on  the  part 
of  patients,  to  make  their  true  situation  properly 
known. 

Into  what  divisions  should  we  separate  leucor- 
rhoea? Into  uterine  leucorrhoea,  and  vaginal  leu- 
corrhoea, a  distinction  some  think  important  to  be 
made. 

What  are  the  rational  signs  of  leucorrhoea  being 
uterine  ?  1.  It  often  comes  on  as  the  precursor  of 
beginning  menstruation.  2.  It  sometimes  occurs  im- 
mediately before  the  red  discharge,  and  again  exists, 
after  the  red  discharge  has  ceased,  thus  leaving  the 
patient  only  one  or  two  weeks  freedom  from  any  dis- 
charge. 3.  Sometimes  uterine  leucorrhoea  entirely 
substitutes  the  red  menstrual  secretion. 

What  other  circumstances  have  been  noted  in  re- 
gard to  it  ?  It  sometimes  comes  on  about  the  critical 
period ;  rarely  is  seen  after  the  fiftieth  year  of  life, 
and  is  most  frequently  preceded  or  accompanied 
by  symptoms  of  uterine  irritation  ;  it  also  often 
follows  abortion,  and  even  some  cases  of  parturition 
at  term. 

What  symptoms   are   usually   attendant  upon   the 


OF   THE    HUMAN    FEMALE.  335 

irruption  of  leucorrhoea  ?  Sometimes  they  are  acute, 
resembling  those  of  menstruation,  or  even  of  dysme- 
norrhoea;  as  pain  in  the  back,  fever,  sometimes  ner- 
vous disturbance,  as  hysteria,  &c.,  flatulency,  dysuria, 
pain  down  the  thighs,  fulness  and  sense  of  tension  of 
the  labia ;  after  these  bad  feelings  have  existed  a  time, 
the  discharge  usually  comes  on. 

CHARACTER  OF  THE  DISCHARGE. 

What  is  the  general  character  of  the  discharge  ? 
Generally  it  is  serous,  or  watery,  and  perfectly  tran- 
sparent ;  sometimes  it  is  mucous,  and  occasionally  it 
is  albuminiform  and  adhesive. 

Whence  is  this  adhesive  secretion  thought  to 
originate  ?  From  the  glands  in  the  neck  of  the 
uterus. 

What  are  some  of  the  physico-chemical  characters 
of  uterine  leucorrhoea  ?  Columbat,  upon  the  author- 
ity of  Donnd,  says  mucus  secreted  by  the  uterus  is 
always  alkaline,  restores  the  blue  color  of  the  litmus 
paper  ;  turns  the  syrup  of  violets  green,  and  has 
such  a  slimy,  ropy  and  tenacious  consistence,  that 
it  can  be  detached  from  the  os  uteri  only  with  great 
difficulty. 

How  long  may  the  disturbances  resulting  in  leu- 
corrhoea continue  ?  From  a  few  hours  to  several 
days. 

CHRONIC    LEUCORRHCEA. 

What  are  the  symptoms  of  chronic  leucorrhoea  ? 
They  are  the  same  as,  but  less  intense  than,  the 
acute.  They  sometimes  occur  in  the  interval  of  the 
menses,  though  the  discharge  sometimes  substitutes 
the  catamenia.  Chronic  leucorrhoea  is  usually  less 
inflammatory,  but  still  it  exhausts  the  patient  if  long 
continued. 

What  is  the  result  to  the  constitution,  of  the 
exhaustion  by  such  secretions  ?  Increased  irrita- 
bility, in  proportion  to  the  reduction  of  strength. 


336  PHYSIOLOGY   AND    PATHOLOGY 

What  is  probably  the  correct  opinion  respecting 
many  cases  of  disease  in  females  called  spinal  irrita- 
tion ?  That  in  very  many  cases  they  originate  in 
irritation,  from  displacement  or  otherwise,  in  the 
uterus. 

How  does  Dr.  Hodge  trace  up  the  chain  of  morbid 
nervous  actions  or  sympathies  in  these  cases  ?  If  a 
patient  have  uterine  irritation  or  leucorrhoea,  irrita- 
tion is  extended  to  the  spine,  and  may  finally  induce 
universal  neuralgia — as  odontalgia,  otalgia,  &c.,  &c., 
dyspnoea,  palpitation,  dyspepsia,  &c. 

To  what  point  should  we  direct  our  remedies  in 
such  cases  ?  To  the  cure  of  the  original  uterine  irri- 
tation, and  then  the  other  affections  will  subside,  if 
they  have  not  been  too  long  continued. 

What  characteristics  of  the  discharge  distinguish 
the  chronic  from  the  acute  form  of  leucorrhoea  ?  In 
the  chronic  form  the  discharge  is  usually  thinner  than 
in  the  acute  variety. 

Which  variety  is  most  obstinate  and  difficult  to  cure? 
That  which  is  thick  like  albumen. 

What  relation  does  this  leucorrhoeal  secretion  hold 
to  the  morale  of  the  female  who  is  subject  to  it  ?  Cer- 
tain moral  causes  or  impressions  act  upon  this  secre- 
tion to  aggravate  it,  and  this  again  seems  to  re-act  upon 
the  morale  of  the  patient  and  render  it  more  irritable. 

How  are  we  to  explain  the  occurrence  of  leucorrhoea 
in  place  of  menstruation  ?  In  some  cases  the  excite- 
ment in  the  uterus  is  not  sufficient  to  cause  a  red  dis- 
charge ;  when  the  excitement  is  not  very  great  we 
may  have  leucorrhoea ;  but  again,  when  the  excitement 
is  inordinately  high,  even  monorrhagia  may  be  the  con- 
sequence. 

What  are  some  of  the  prominent  causes  of  leucorr- 
hoea ?  Want  of  cleanliness,  over  stimulation  of  the 
organs  by  prostitution,  &c. 

Stimulating  emmenagogues,  the  irritation  of  foreign 
bodies    as  pessaries,   &c. ,   particular   diseases   of  the 


OF   THE    HUMAN    FEMALE.  337 

uterus,  including  displacements,  abortions,  remains  of 
placenta,  &c.   &c. 

Are  we  to  regard  leucorrhoea  as  the  result  of  an  in- 
flammatory action  ?  By  some  very  respectable  autho- 
rity it  is  regarded  as  rarely  inflammatory,  but  as  the  re- 
sult of  a  moderate  degree  of  irritation  or   excitement. 

How  is  simple  leucorrhoea  to  be  distinguished  from 
the  specific  affection  called  gonorrhoea  ?  In  gonorr- 
hoea there  is  usually  ardor  urinse,  and  it  is  said  by  some 
surgeons  that  a  discharge  may  be  actually  squeezed 
from  the  urethra  in  cases  of  gonorrhoea,  while  neither 
of  these  symptoms  attend  simple  leucorrhoea. 

How  are  we  to  diagnosticate  uterine  from  vaginal 
leucorrhoea  ?  By  the  fact  that  the  former  is  connect- 
ed with  menstruation,  sometimes  complicated  with  it, 
and  sometimes  becomes  a  vicarious  substitute  for  it. 

What  are  the  distinguishing  characters  of  true  vagi- 
nal leucorrhoea  as  described  by  some  of  the  French  physi- 
ologists ?  True  leucorrhoea  is  thick  and  creamy,  will 
not  adhere  to  the  fingers ;  reddens  litmus  paper  and 
appears  to  be  composed  of  little  oval  bodies,  resemb- 
ling pellicles  Or  scales  from  the  mucous  membrane. 

What  are  the  microscopic  signs  of  the  existence  of 
venereal  vaginitis,  or  blenorrhagia  'r*  Columbat  sa3^s  the 
discharge  is  always  composed  of  pus  mixed  with  the 
proper  mucus  of  the  vagina.  Donne  declares  that  pus 
globules  are  discovered  by  placing  a  drop  of  the  muco- 
purulent fluid  between  two  fine  glasses,  and  examining 
them  with  the  microscope  of  250  to  300  diameters. 
These  infusory  animals,  whose  bodies  are  transparent, 
and  of  round  or  oval  form,  with  a  diameter  of  jio  ^^ 
j'y  of  a  millimetre,  are  most  commonly  united  in 
groups  of  from  two  to  six  individuals — when  examined 
by  the  light  of  a  lamp  they  may  sometimes  be  seen  to 
move,  more  especially  to  agitate  in  every  direction  a  long 
filiform  and  very  delicate  appendage,  which  serves  to 
distinguish  them  from  the  spherical  and  inanimate  glo- 
bules of  true  phlegmonous  pus,  in  which  latter  the  trico- 
monas  never  is  observed. 

29 


3 '18  PHYSIOLOGY   AND    PATHOLOGY 

What  is  a  Millimetre  ?  The  thirtj-nlne  thousandth 
part  of  an  inch. 

TREATMENT  OF  LEUCORRHCEA. 

What  rules  of  treatment  are  we  to  observe  for  ute- 
rine leucorrhoea  ?  The  same  that  have  been  laid  down 
for  the  management  of  cases  of  emansio  mensium  or 
chlorosis.  When  connected  with  monorrhagia,  to  be 
treated  as  such. 

What  is  to  be  done  with  those  cases  of  leucorrhoea 
dependant  upon  displacement  of  uterus,  the  presence 
of  foreign  bodies,  or  diseases  of  the  uterus  ?  Remove 
the  cause  by  appropriate  treatment,  and  the  leucorr- 
hoea will  soon  subside. 

What  treatment  is  necessary  for  the  acute  form  of 
leucorrhoea  ?  Some  cases  require  antiphlogistics,  as 
general  bleeding,  or  cups,  leeches,  and  alteratives,  and 
after  reduction  of  general  excitement,  the  use  of  pro- 
per local  remedies,  as  tepid  and  cold  injections  of  mu- 
cilage into  the  vagina.  If  much  irritation  exists  in  the 
parts,  warm  fomenting  injections  should  be  used  to 
favor  the  discharge. 

What  should  be  done  if  the  disease  persist  notwith- 
standing the  use  of  these  remedies  ?  Revulse,  by  blis- 
ters upon  the  sacrum,  and  hypogastrium  ;  and  if  these  do 
not  succeed,  treat  it  as  a  case  of  uterine  irritation. 

What  is  the  duty  of  the  physician  in  attempting  the 
management  of  chronic  cases  of  leucorrhoea  ?  To  dis- 
cover if  possible,  and  remove  the  predisposing,  the 
actual  and  the  aggravating  causes. 

What  may  be  said  respecting  the  use  of  local  reme- 
dies ?  That  in  general  too  much  reliance  is  placed 
upon  them,  and  too  little  regard  had  to  the  improvement 
of  the  general  health  by  proper  constitutional  remedies. 

What  remedies  have  been  thought  to  act  directly 
upon  the  secretory  surfaces  of  the  uterus  and  vagina  ? 
Of  those  to  be  used  internally  or  by  the  stomach,  the 
balsam  of  copaiba,  the  spirits  of  turpentine,  the  tinc- 
ture of  cantharides.   In  the  menorrhagic  leucorrhoea,  or 


OF   THE    HUMAN   FEMALE.  839 

that  complicated  with  menorrhagia,  the  ergot  has 
been  prescribed  ;  some  of  the  preparations  of  iodine 
have  been  thought  useful ;  externally  the  use  of  con- 
tinued blisters,  or  of  pustulation  from  tartar  emetic 
ointment,  with  cold  douches  to  the  back  and  into  the 
vagina,  have  been  useful,  in  allaying  the  local  irritation. 
When  may  we  hope  to  derive  benefit  from  astrin- 
gent injections?  When  the  constitutional  and  local 
excitement  have  been  subdued  by  the  means  already 
pointed  out. 

VAGINAL  LEUCORRHCEA. 

What  is  to  be  said  respecting  the  frequency  of  va- 
ginal leucorrhoea  ?  It  is  more  common  than  that  from 
the  uterus,  and  very  many  females  are  incident  to  it. 

What  are  the  causes  of  vaginal  leucorrhoea  ?  The 
irritations  from  certain  foreign  bodies  in  the  vagina, 
as  pessaries,  &c.  The  use  of  instruments  in  terminat- 
ing labor,  or  abortion ;  violence  done  to  the  vagina  in 
the  commission  of  rape,  &c.  Chemical  or  vital  irri- 
tants, as  stimulating  injections,  the  escape  of  urine  into 
vagina,  acrid  discharges  from  the  uterus,  the  presence 
of  tumors  in  the  uterus  and  vagina,  &c.,  excessive  ve- 
nery,  or  prostitution,  &c.  &c. 

How  far  may  leucorrhoeal  discharge  depend  upon 
enfeebled  condition  of  the  general  health  ?  It  is  some- 
times dependant  upon  this  condition  of  the  general 
health  entirely. 

To  what  extent  is  it  dependant  upon  sympathetic 
irritation  in  other  parts  ?  It  is  known  in  some  instan- 
ces to  be  caused  by  gastric  irritation,  by  ascarides  in 
the  rectum,  by  diseases  in  the  anus,  as  hemorrhoids, 
fistulae,  &c. 

How  far  may  habits  of  life,  and  the  condition  of  cli- 
mate operate  in  its  production  ?  They  may  have  con- 
siderable influence.  The  women  Avho  use  foot  stoves, 
who  indulge  in  various  luxurious  habits,  or  who  reside 
in  very  moist  climates,  are  said  to  'he  more  prone  to  it 
than  those  under  different  circumstances. 


340  PHYSIOLOGY   AND    PATHOLOGY 

VAGINITIS. 

To  what  state  of  the  vagina  is  it  owing  ?  General- 
ly to  an  inflamed  state  of  the  canal. 

Is  it  more  common  in  the  married  or  unmarried  fe- 
male ?  In  the  married  female,  though  even  very 
young  girls  are  sometimes  affected  with  it. 

What  are  the  symptoms  of  vaginitis  ?  There  is  p^ 
sense  of  fulness  in  the  pelvis,  sometimes,  though  rarely 
pain,  but  more  frequently  a  sensation  of  heat  in  the 
course  of  the  vagina  :  with  this  there  is  often  tenes- 
mus, and  a  mucous  discharge  from  the  rectum,  also 
dysuria,  the  urine  being  natural  in  quality,  but  the  ca- 
nal of  the  urethra  irritable  from  the  extension  of  the 
irritation  from  the  vagina. 

DIFFERENT  STAGES. 

Into  how  many  stages  do  some  authors  divide  this 
aifection  ?  Into  two,  the  acute  or  severe,  and  the 
chronic  or  mild  stages,  or  forms. 

What  is  the  usual  character  of  the  discharge  in  the 
severe  form  ?  It  is  acrid,  sometimes  red,  like  bloody 
serum. 

What  is  it  when  the  inflammation  is  milder  ?  It  re- 
sembles mucus  or  muco-puruloid  matter ;  sometimes 
it  is  of  a  greenish  color  ;  when  the  affection  has  be- 
come decidedly  chronic,  the  discharge  is  usually  of  a 
thin  yellowish  color. 

How  does  acute  vaginitis  usually  terminate  ?  By 
resolution,  or  it  runs  into  a  chronic  or  milder  form. 

To  what  extent  does  it  go  when  it  is  very  severe 
and  somewhat  protracted  ?  It  then  may  involve  the 
muscular  or  fibrous  coat ;  unless,  however,  the  mucous 
coat  shall  have  been  destroyed  b}^  the  inflammation,  or 
ulceration,  or  by  a  wound,  the  surfaces  do  not  become 
adherent  to  each  other.  In  some  instances,  moreover, 
sloughing  does  actually  take  place. 

GONORRHO^AL  VAGINITIS. 
What  is  the  diagnosis  of  gonorrhoeal  inflammation 
of  the  vagina  ?     In  this  variety  of  vaginitis  there  is  ar- 


OF    THE    UUMAN    FEMALE.  341 

dor  urinae,  inflammation  in  the  inguinal  lymphatics, 
and  in  the  severer  forms,  ulcerations  of  the  os  tincae 
have  been  observed. 

Is  it  necessary  that  the  vaginitis  shall  be  of  a  speci- 
fic character,  to  produce  an  irritation  in  the  penis  from 
the  act  of  coition  ?  Leucorrhoea  per  se  may  be  so  acrid 
as  to  cause  irritation  in  the  male  organ  when  exposed 
to  contact  with  it. 

TREATMENT  OF  VAGINITIS. 

What  is  the  appropriate  treatment  of  acute  leucor- 
rhoea ?  Vascular  and  intestinal  depletion,  revulsive, 
&c.  If  the  general  vascular  system  be  affected,  ven- 
esection, saline  cathartics,  low  diet  ; — locally,  cups  to 
the  back,  or  leeches  to  the  vulva  ;  then  promote  secre- 
tion by  warm  hip  bath,  warm  mucilaginous  injections 
into  the  rectum  and  vagina. 

What  is  proper  after  the  inflammation  has  been  re- 
duced ?  Astringent  washes,  as  solutions  of  sulphate  or 
acetate  of  zinc,  acetate  of  lead,  alum,  borax,  nitrate 
of  silver. 

What  peculiar  effect  does  alum  produce  ?  It  coagu- 
lates the  secretion,  particularly  if  the  alum  be  previ- 
ously burnt,  or  thoroughly  dried. 

Suppose  the  inflammation  to  have  been  such  as  to  be 
followed  by  adhesions  of  the  walls  of  the  vagina,  what 
treatment  should  be  persued  ?  The  contractions  and 
occlusions  thus  formed  should  be  overcome  by  the  use 
of  bougies  or  other  proper  dilating  instruments. 
CHRONIC  LEUCORRHCEA. 

What  are  some  of  the  causes  of  chronic  leucorrhoea  ? 
Chronic  inflammation  of  the  vagina,  displacements  of 
the  uterus,  ulcerations  in  the  vagina,  or  uterus,   &c. 

Can  chronic  leucorrhoea  be  readily  distinguished 
from  chronic  gonorrhoea  ?  It  is  almost  impossible  to 
make  out  the  difference  between  them. 

TREATMENT  OF  CHRONIC  LEUCORRH(EA. 

What  are  the  general  indications  in   the  treatment 
29* 


342  PHYSIOLOGY   AND    PATHOLOGY 

of  the  chronic  form  of  leucorrhoea  or  vaginitis  ?  To 
improve  the  general  health  by  the  use  of  fresh  air, 
wholesome  diet,  tonics,  alteratives,  as  preparations  of 
iodine,  &c. ;  then  resort  to  local  treatment ;  if  there  be 
ulcerations,  first  cure  them.  As  alterative  remedies, 
the  balsam  of  copaiba,  and  tincture  of  cantharides, 
have  had  some  reputation. 

Have  we  probably  any  specific  for  the  cure  of  this 
complaint  ?  Nothing  which  can  be  relied  upon  as 
such. 

What  kind  of  topical  applications  are  best  when 
the  system  has  been  prepared  for  their  use  ?  As- 
tringent washes  of  decoctions  of  logwood,  nutgalls,  oak 
bark,  &c. 

Should  any  rule  be  observed  in  reference  to  the 
mode  of  application  ?  They  should  be  passed  slowly, 
but  far  up,  to  distend  the  whole  vagina,  and  bring  the 
remedy  in  contact  with  the  whole  mucous  surface. 

What  mineral  astringents  are  useful  ?  The  sulphate, 
or  acetate  of  zinc,  or  of  lead,  one  drachm  to  half  pint 
of  mucilage  of  gum  arable,  to  render  it  slightly  ad- 
hesive to  the  vaginal  surface.  The  alum,  as  mentioned 
in  the  reduced  state  of  acute  vaginitis,  is  particularly 
useful. 

What  is  the  probable  origin  of  the  pure  milky  white 
discharge  which  occurs  in  some  cases  ?  Its  origin  is 
not  well  defined ;  it  is  sometimes  supposed  to  come 
from  the  glands  of  the  neck  of  the  uterus,  but  it  has 
been  seen  issuing  from  the  vulva. 

What  is  the  best  mode  of  cure  of  the  peculiar  state 
giving  rise  to  this  discharge  ?  The  application  of  the 
solid  nitrate  of  silver,  or  a  strong  solution  of  the  arti- 
cle to  the  part  affected. 

PAIN  IN  THE  BACK,  &c.,  NOT  ALWAYS  DEPENDANT  UPON 
VAGINITIS. 

Upon  what  affections  besides  those  of  the  uterus 
may  the  pain  in  the  back,  &c.,  depend  ?  It  may  be 
caused  by  some  disease  in  the  kidneys,  in  the  bladder, 


OF   THE    HUMAN    FEMALE.  343 

&c.,  or  it  may  be  of  a  neuralgic,  or  rheumatic  origin, 
independent  of  any  uterine  afiection. 

In  those  dorsal  or  lumbar  pains  accompanying  dis- 
turbance of  the  uterus,  is  the  pain  constant  or  inter- 
mittent ?  It  is  sometimes  intermittent,  paroxysmal, 
and  of  a  neuralgic  character ;  it  is  mostly  moderated 
by  assuming  the  recumbent  position ;  though  some- 
times the  pain  is  constant  even  when  lying  down. 

Are  these  painful  sensations  necessarily  the  result 
of  inflammation  ?  They  do  not  always  depend  upon 
inflammation,  but  frequently  upon  a  state  of  irritation. 

IRRITABLE  UTERUS. 

What  are  we  to  understand  by  the  phrase  "  ijTitahle 
uterus  f  A  morbid  sensibility  of  this  organ,  without 
inflammation  or  change  of  structure ;  a  condition 
which  has  continued  in  some  cases  for  several  years 
without  afi'ecting  any  organic  lesion  perceptible  to  the 
senses. 

What  influence  does  this  irritability  of  the  uterus 
appear  to  have  over  the  exercise  of  its  functions  ?  It 
causes  them  all  to  be  painfully  performed. 

What  is  the  eff'ect  of  touching  the  uterus  while  it  is 
in  an  irritable  state  ?  It  is  extremely  painful,  some- 
times causing  the  patient  to  scream. 

Can  the  function  of  reproduction  be  carried  on 
in  cases  of  irritable  uterus  ?  Sterility  mostly,  though 
not  perhaps  always,  accompanies  irritable  uterus. 

What  are  the  principal  causes  of  irritability  of  the 
uterus  ?  Disturbance  of  function,  and  displacements 
of  the  uterus ;  in  some  cases,  it  is  dependent  upon 
the  character  of  the  constitution,  frequent  labors, 
abortions,  &c. 

By  what  circumstances  is  the  sensibility  aggra- 
vated ?  By  distension  of  bladder,  or  rectum  ;  by 
any  severe  exercise  which  causes  pressure  upon  the 
uterus. 

Is  this  afl'ection  necessarily  complicated  with  any 
other  ?     It  often  exists  entirely  alone,  but  in  some 


344  PHYSIOLOGY   AND    PATHOLOGY 

instances  it  is  combined  with  an  inflammatory  state  of 
the  organ. 

What  influence  may  depressed  or  disturbed  states 
of  mind  have  over  the  production  of  this  affection  ? 
They  may  exert  so  potent  an  influence  as  to  require 
the  condition  of  the  mind  to  be  improved  before  any 
other  treatment  can  be  eff'ectual. 

What  consequences  may  irritable  uterus  produce  if 
not  speedily  cured  ?  Dysmenorrho^a,  or  menorrhagia, 
or  a  train  of  morbid  sensibility,  or  nervous  excitability, 
hysteria,  spinal  irritation,  &c. 

TREATMENT  OF  lERITABLE  D  TERUS. 

What  are  the  curative  indications  in  irritability  of 
the  uterus  ?  The  removal  of  any  or  all  the  causes 
which  have  produced  it.  Thus,  if  there  be  any  dis- 
placement of  the  uterus,  it  must  be  properly  restored, 
and  kept  in  its  proper  situation  by  mechanical  or 
other  efficient  means.  If  it  has  come  on  after  any 
violent  effort  of  the  uterus,  as  after  labor,  or  abortion, 
the  patient  must  be  kept  quiet,  and  her  bowels  moder- 
ately open ;  if  there  be  any  local  inflammatory  excite- 
ment, leeches  may  be  applied  to  the  sacrum  or  groins. 

Is  there  any  objection  to  the  application  of  leeches 
directly  to  the  uterus  in  case  of  irritability  of  that  or- 
gan ?  Their  application  would  be  painful,  and  some- 
times aggravating. 

What  constitutional  remedies  should  be  employed  ? 
During  the  three  weeks  immediately  succeeding  the 
menstrual  discharge,  she  should  use  the  cold  bath, 
either  local  or  general,  with  a  view  to  obtain  a  reaction 
and  healthy  glow  of  warmth,  and  by  thus  increasing 
the  strength,  diminish  the  irritability  of  the  nervous 
system ;  cold  douches  down  the  back — cold  water 
into  the  vagina — large  quantities  of  cold  water  into 
the  rectum  and  colon  to  distend  them,  and  produce 
the  two-fold  eff'ect  of  removing  the  feces  and  giving 
tone  to  the  nerves. 

What  rule  for  diet  and  exercise  should  be  observed? 


OF   THE    HUMAN    FEMALE.  345 

In  the  tnore  chronic  or  protracted  form,  the  diet 
should  be  nutritious,  and  solid  or  animal,  and  not  en- 
tirely vegetable.  The  patient  should  be  carried  out 
into  the  open  air  whenever  possible,  and  she  should 
use  exercise  on  foot  whenever  she  is  able,  without 
aggravating  her  symptoms. 

What  is  to  be  said  respecting  counter-irritants? 
They,  such  as  tartar  emetic,  croton  oil,  moxa,  and  per- 
petual blisters  or  setons  seem  to  be  in  general  too  irri- 
tating to  the  system,  and  rather  aggravate  than  relieve. 

Under  what  circumstances  are  narcotics  called 
for  ?  During  severe  attacks  of  pain,  the  cicuta  in 
two  grain  doses,  three  or  four  times  a  day,  gradually 
increasing  the  quantity  if  necessary ;  stramonium, 
belladonna,  hyosciamus,  lactucarium,  &c.,  are  some- 
times very  useful  in  allaying  the  pain,  provided  the 
use  of  them  is  continued  through  several  weeks. 

What  alterative  tonic  have  we  which  is  often  useful 
in  these  cases  ?  Lugol's  solution  of  iodine,  or  the  hy- 
driodate  of  potash.  Five,  ten,  or  twelve  drops,  three 
times  a  day,  of  the  strong  solution,  continued  a  long 
time,  often  improves  the  appetite  and  the  vigor  of  the 
general  system. 

What  other  parts  of  the  pelvic  viscera  of  the  fe- 
male have  been  observed  to  be  subject  to  this  morbid 
irritability  ?     The  vagina,  vulva,  and  urethra. 

What  treatment  is  proper  for  these  cases  ?  The 
same  as  for  irritable  uterus. 

DISPLACEMENTS  OF  THE  UTERUS— PROLAPSUS. 

To  what  variety  of  displacements  is  the  uterus  sub- 
ject ?  To  prolapsus  in  its  several  degrees — to  retro- 
version partial  and  complete — to  anteroversion — to 
anteflection — to  retroflection,  and  to  a  hernial  dis- 
placement. 

Are  either  of  these  displacements  capable  of  being 
positively  diagnosticated  by  the  rational  or  sympa- 
thetic signs  ?  No ;  there  are  numerous  other  affec- 
tions liable  to  occur  in  the   female  pelvis,  which  give 


846  PHYSIOLOGY   AND    PATHOLOGY 

signs  strongly  resembling  displacements.  Thus,  con- 
gestions of  the  uterus,  irritable  uterus,  irritable 
urethra,  irritable  vagina,  irritable  rectum,  polypous  and 
other  tumors  in  the  uterus  or  vagina,  ascarides  in  the 
rectum,  or  accumulation  of  hardened  feces  in  that 
intestine,  have  all  produced  sympathetic  symptoms 
similar  to  those  of  prolapsus  or  other  displacements. 

SYMPTOMS  ATTENDANT  UPON  DISPLACEMENTS  OF 
THE  UTEEU&. 

What  are  the  symptoms  usually  attendant  upon 
displacement  ?  Many  of  the  symptoms  of  local  in- 
flammation— weight  in  the  pelvis  wliile  in  the  erect 
position — bearing  down — disposition  to  strain,  as  if 
to  evacuate  the  bladder  or  bowels — sensation  as 
though  something  must  fall  away — pain  in  the  sacro- 
lumbar  region,  thence  all  round  to  the  hypogastrium ; 
pains  in  the  bones  of  the  pubes,  probably  from  the 
stretching  of  the  round  ligaments  :  this  is  relieved  at 
once  by  lying  down — pains  sometimes  intermittent, 
like  those  of  labor — a  more  or  less  fixed  pain  in  the 
side,  sometimes  in  one  side,  sometimes  in  the  other, 
sometimes  in  the  one  inguinal  region  or  the  other,  and 
often  with  a  sense  of  dragging  from  the  umbilicus. 

What  effect  has  certain  states  of  the  bowels  on  the 
feelings  of  patients  who  have  displacements  of  the 
uterus  ?  If  the  bowels  are  moved  regularly  and  with- 
out effort,  and  the  patient  is  not  in  a  highly  irritable 
condition,  she  may  feel  comparatively  well ;  but  if  the 
bowels  be  constipated,  the  weight  of  the  feces  aggra- 
vates the  feelings  of  the  patient :  and  if  she  hajve  a 
diarrhoea,  the  frequent  actions  of  the  bowels  greatly 
increase  her  distress,  by  still  more  dragging  down  the 
uterus. 

Which  most  sympathises  in  this  local  disturbance 
of  the  uterus,  the  vascular  or  nervous  system  ?  The 
vascular  system  is  usually  little  affected,  but  the  ner- 
vous sympathies  often  become  very  extensive  ;  thus, 
the  spinal  marrow,  or  the  brain  itself,  takes  on  the  char- 


OF    THE    HUMAN    FExMALE.  347 

acter  of  spinal  or  cephalic  irritation,  and  in  time  the 
neuralgia  of  almost  every  organ  may  occur  in  succes- 
sion or  simultaneously. 

What  appears  to  be  proof  that  this  irritation  has 
depended  upon  displacement  of  the  uterus?  The 
fact  in  some  cases  instantly,  and  in  most  others  sooner 
or  later,  all  these  distressing  affections  have  ceased 
after  the  restoration  of  the  uterus  to  its  proper  place. 

TRUE  METHOD  OF  DIAGNOSIS. 

As  there  are  many  other  affections  already  alluded 
to,  which  cause  symptoms  resembling  displacements 
of  the  uterus,  is  it  proper  that  the  physician  should 
at  once  determine,  by  physical  examination,  what  the 
true  diagnosis  is?  This  should  be  regarded  as  a  fun- 
damental rule  in  the  duty  of  treating  diseases,  but  as 
in  this  case  the  feelings  of  both  patient  and  physician 
should  be  spared  if  possible,  it  has  been  advised  first 
to  treat  all  these  acute  symptoms  by  rest  in  bed,  with 
the  head  and  shoulders  low,  light  diet,  laxative  medi- 
cine, warm  fomentations,  warm  injections,  and  if  ap- 
parently necessary,  leeches  to  the  groins,  and  the  in- 
ternal use  of  such  mild  narcotics,  as  will,  under 
ordinary  circumstances  of  irritation,  quiet  the  sys- 
tem. 

TREATMENT  OF  DISPLACEMENTS. 
Suppose  the  train  of  symptoms  denoting  engorge- 
ment, irritability,  or  displacement  of  the  uterus,  should 
occur  in  a  patient  at  any  time,  what  treatment  should 
be  adopted  ?  If  after  a  careful  examination  by  the 
touch,  of  the  parts  concerned,  prolapse  or  retrover- 
sion is  detected,  it  should  be  reduced,  if  possible, 
at  once,  and  if  this  do  not  afford  the  desiied  relief, 
let  the  patient  be  kept  in  a  horizontal  position  on  a 
bed  or  sofa  for  the  requisite  number  of  days,  even  if 
the  time  so  occupied  continue  for  several  weeks,  in 
order  to  give  the  parts  an  opportunity  to  recover  their 
healthy  condition,  and  as  soon  as  the  parts  will  bear 


348  PHYSIOLOGY    AND    PATHOLOGY 

it,  a  proper  pessary  should  be  used  to  support  it,  if  the 
vagina  and  the  uterine  ligaments  have  not  sufficient 
tone  to  justify  the  hope  that  the  recovery  may  be  well 
secured  without  it. 

When  the  acute  symptoms  have  been  relieved  by 
rest  or  otherwise,  what  is  mostly  necessary  to  com- 
plete the  cure  or  afford  permanent  relief  to  the  displace- 
ment, while  the  patient  is  recruiting  her  general  health 
by  exercise  ?  Such  mechanical  support  as  will  retain 
the  uterus  in  its  proper  situation  until  the  general 
health  becomes  restored,  and  the  ligaments  of  the 
uterus  acquire  their  natural  tonicity. 

PESSARIES. 

What  is  the  general  history  of  the  artificial  means 
of  support  for  the  uterus  ?  From  the  earliest  re- 
cords of  medicine,  instruments  called  pessaries  have 
been  in  use.  They  have  been  composed  of  various  me- 
dicated substances,  which  have  been  supposed  to  exert 
resolvent,  or  softening,  or  astringent,  or  tonic  influ- 
ences upon  the  parts  with  which  they  were  placed  in 
contact.  In  most  cases,  recently,  they  are  used  for  the 
purpose  of  affording  mechanical  support  to  a  prolapsed 
vagina,  bladder,  or  uterus. 

Of  what  is  the  pessary  usually  made  ?  Of  cork, 
covered  with  wax  ;  of  linen  stuffed  with  hair,  or  wool,  or 
oakum,  and  varnished  ;  of  sponge;  of  box-wood,  ivory; 
of  coiled  wire  covered  with  leather  or  gummed  cloth ; 
of  caoutchouc  bags  or  balls ;  of  small  bladders,  or 
birds'  craws  filled  with  air ;  of  eggshells  from  which 
the  contents  had  been  extracted ;  and  various  other 
materials  which  circumstances  might  seem  to  indicate 
or  ingenuity  invent.  Some  persons  have  sewed  up 
tan  in  linen  bags,  soaked  them  in  wine,  and  while  so 
moistened  inserted  them  into  the  vagina. 

What  are  some  of  the  varieties  of  form  of  the  pes- 
sary ?  Globular,  globe-depressed  on  one,  or  opposite 
sides;  oblong,  bung  or  biscuit-shaped,  cylindrical,  or 
cyiindroidal,  ovoidal : — indeed  of  almost  e\erj  other 


OF   THE   HUMAN    FEMALE.  349 

imaginable  variety  of  shape,  according  to  tlie  supposed 
condition  of  the  parts  to  which  they  were  to  be  ap- 
plied. Some  have  been  made  ring-shaped,  others  like 
an  oval  link  of  a  chain ;  some  of  these  have  been  thus 
oval  with  the  conjugate  diameter  shortened,  making  it 
resemble  the  figure  of  the  plane  of  the  superior  strait ; 
others,  oblong  and  curved  on  one  of  the'  planes  or 
aspects,  to  look  like  the  frame  of  a  large  shoe-buckle ; 
while  others  again  have  been  finished  like  a  huge  letter 
U,  or  bow  of  an  ox-yoke,  and  curved  upon  one  of  its 
broad  planes  with  a  view  to  adapt  such  curvature  to 
the  natural  axis  of  the  vagina.  Quite  recently  we 
have  a  ring  made  of  watch-spring  steel  and  covered 
with  gutta  percha,  that  it  may  be  compressed  into  a 
long  ellipse  at  the  time  of  inserting  it,  and  afterwards 
expand  to  the  capacity  of  the  vagina. 

What  are  the  materials  of  which  the  pessary  should 
be  composed  whenever  practicable  ?  Glass,  or  silver 
well  gilt,  or  pure  gold. 

What  are  mostly  entitled  to  preference  ?  1.  The 
common  flat  circular  form.  2.  The  ring-shaped,  with 
very  thick  edges.  3.  The  oval-rfng,  curved  upwards 
at  one  or  both  extremities. 

What  is  the  objection  to  the  globular  pessary  ? 
1.  It  is  introduced  through  the  osteum  vaginae  with 
difiiculty.  2.  It  does  not  always  sustain  the  uterus 
in  its  natural  situation.  3.  It  is  often  extremely  diffi- 
cult to  remove  it  when  it  has  been  introduced. 

What  position  should  the  round  flat  pessary  occupy 
in  the  vagina  ?  It  should  be  parallel  with  the  rec- 
tum, that  is,  its  convex  surface  should  be  applied  to 
the  rectum,  with  its  upper  edge  in  the  cul-de-sac  of 
the  vagina,  and  its  lower  edge  upon  the  perin«3um. 

Is  the  uterus  then  supported  in  the  direction  of  the 
thickness,  or  the  diameter  of  the  pessary  ?  It  cannot 
be  eifectually  supported  in  any  other  than  the  direc- 
tion of  the  diameter  of  the  pessary. 

In  what  way  does  the  pessary  appear  to  act  in  the 
support  of  the  uterus  ?  As  a  lever,  of  which  the  con- 
30 


B^  PHYSIOLOGY    AND    PATHOLOGY 

vex  surface  rests  upon  the  rectum  as  a  fulcrum,  and 
the  muscles  of  the  perinneum  act  at  the  lower  edge, 
while  the  uterus  is  supported  upon  the  upper  edge. 

Which  form  of  pessary  has  been  regarded  as  best 
for  the  support  of  a  retroverted  uterus  ?  The  oblong 
or  elliptical  ring  pessary,  which  must  be  long  enough 
to  have  one  of  its  extremities  go  up  behind  the  neck 
and  under  the  body  of  the  uterus,  while  the  other  end 
is  supported  by  the  perinoeum,  or  by  the  pubes. 

What  class  of  pessaries  are  supposed  to  be  best  for 
females  who  have  had  many  children,  or  those  affected 
with  irritable  uterus,  or  those  who  have  ulcerations 
upon  the  os  uteri  ?  First,  the  oval  pessary  ;  next, 
the  ring  pessaries  with  edges  sufficiently  thick  to 
elevate  the  uterus  from  contact  with  the  floor  of  the 
vagina. 

What  consequences  may  result  from  having  the 
pessary  too  small  ?  Both  pessary  and  uterus  may 
become  prolapsed  or  retroverted. 

What  is  to  be  said  of  the  stem  pessary,  or  the  pes- 
sary resembling  the  stem  and  bottom  of  a  wine-glass  ? 
It  is  usually  too  irritating  to  be  useful. 

What  is  the  first  thing  essential  to  the  successful 
use  of  the  pessary  ?  That  the  uterus  be  replaced  in 
its  natural  situation,  for  without  this  the  pessary  will 
fail  to  answer  the  purpose  intended. 

MANNER  OF  INTRODUCING  THE  PESSARY. 

What  is  the  proper  method  of  introducing  a  pes- 
sary ?  Frequently  it  is  sufficient  that  the  patient  lie 
upon  her  left  side,  with  her  hips  to  the  edge  of  the 
bed.  It  is  usually  more  convenient  for  the  practi- 
tioner that  she  lie  upon  her  back,  and  in  some  diffi- 
cult cases  it  is  necessary  that  she  have  her  hips 
brought  to  the  foot  of  the  bed,  and  her  feet  on  chairs 
each  side  of  the  seat  of  the  practitioner.  The  vulva 
is  then  to  be  well  lubricated,  and  the  posterior  com- 
missure so  put  upon  the  stretch  by  the  index  finger 
of  one  hand,  as  to  dilate   the  orifice  of  the  vagina. 


OF   THE    HUMAN   FEMALE.  351 

The  pessary  also,  well  lubricated,  is  now  to  be  intro- 
duced edgewise  in  the  direction  of  the  long  diameter 
of  the  vagina,  by  making  it  press  firmly  upon  the 
finger,  which  rests  upon  the  posterior  commissure, 
and  taking  care  not  to  allow  the  upper  edge  to  con- 
tuse either  of  the  nymphse,  press  firmly  but  gradually 
onward,  until  it  has  entered  the  orifice  of  the  vagina 
— then  observing  that  it  turns  over  with  its  concave 
surface  upwards — continue  pressing  upon  its  anterior 
edge  till  it  is  made  to  rest  in  the  fossa  in  the  perin- 
seum  behind  the  posterior  commissure  of  the  vulva, 
having  its  upper  edge  completely  imbedded  in  the  cul- 
de-sac  of  the  vagina. 

At  what  part  of  this  operation  does  the  patient 
experience  pain  ?  While  the  instrument  is  passing 
through  the  orifice  of  the  vagina.  It  is  usually  in- 
stantly relieved,  as  soon  as  the  pessary  has  fairly 
passed  beyond  this  point. 

Would  it  not  be  best  to  replace  the  uterus  with  the 
finger,  before  attempting  the  introduction  of  the 
pessary  ?  It  would  always  ^  be  best,  and  in  those 
cases  in  which  the  finger  is  too  short  for  carrying 
up  the  fundus  in  cases  of  retroversion,  it  is  best  to 
elongate  it  by  carrying  up  upon  it  a  flexible  metallic 
bougie,  with  which  the  organ  may  be  replaced. 

What  advantage  can  be  gained  by  passing  a  finger 
into  the  rectum  in  these  cases  ?  The  replacement 
may  thus  often  be  facilitated,  but  operations  through 
the  rectum  are  often  very  painful  to  the  patient. 

What  instructions  should  be  given  to  the  patient, 
if  she  should  feel  that  the  lower  edge  of  the  pessary 
presses  anteriorly  ?  To  insert  the  finger  into  the 
vagina,  and  press  the  instrument  backwards  and  ra- 
ther downwards. 

What  sensation  does  the  patient  usually  experience 
after  the  pessary  is  properly  placed  ?  Sometimes, 
immediate  relief;  this  however  is  not  always  the  case 
for  a  few  days.  In  some  cases,  moreover,  it  cannot  be 
borne. 


352  PHYSIOLOGY   AND    PATHOLOGY 

How  long  Is  it  usually  requisite  for  a  patient  to 
continue  the  use  of  the  pessary  ?  So  long  as  it  re- 
mains in  its  proper  position  without  exciting  irrita- 
tion. Whenever  it  causes  any  considerable  uneasiness, 
it  will  be  proper  to  have  it  removed  to  be  regilded,  or 
to  have  a  substitute  of  a  different  size. 

How  long  may  she  usually  wear  a  glass,  or  a  gilt 
pessary  without  removing  it  ?  In  general  six  months ; 
at  the  end  of  which  time  it  is  usually  necessary  that 
she  have  it  removed  to  be  re-gilded,  or  to  substitute 
one  of  diiferent  size,  whether  it  be  of  glass  or  other 
material. 

How  are  such  pessaries  to  be  kept  clean  in  the 
vagina  ?     By  the  use  of  injections. 

What  can  be  said  of  the  elytroid  pessary  of  Clo- 
quet  ?  That  it  is  not  found  to  answer  the  desired 
purpose. 

OBJECTIONS  TO  PESSARIES. 

What  are  some  of  the  evil  consequences  which 
may  result  from  pessaries  ?  Irritation,  inflamma- 
tion, ulcerations  of  the  vagina  and  orifice  and  neck 
of  the  uterus  ;  when  injudiciously  employed,  or  un- 
suitably constructed,  the  neck  of  the  uterus  has 
become  strangulated  in  the  perforation  of  the  flat 
pessary,  &c. 

What  is  probably  the  cause  of  the  objections  to  the 
use  of  pessaries  for  the  relief  of  prolapsus  and  other 
displacements  of  the  uterus  ?  The  fact  that  they  are 
often  made  of  improper  materials,  unsuitable  forms, 
and  that  those  who  insert  them  misapprehend  the 
manner  of  application,  and  their  mode  of  operation 
for  the  support  of  the  displaced  organs. 

What  should  be  done  if  the  pessary  be  found  pro- 
ducing any  injury  ?  It  should  be  removed  and  its 
use  entirely  abandoned,  or  it  should  be  substituted  by 
one  adapted  to  the  case. 

Is  difficulty  ever  experienced  in  attempts  to  remove 
pessaries  ?     So   much  difliculty  has  occurred  in  at- 


OF   THE   HUMAN    FEMALE.  353 

terapts,  in  some  instances,  that  various  instruments 
have  been  brought  into  requisition  to  aid  in  the 
removal  of  them,  as  forceps,  scissors,  hooks  of  various 
kinds. 

What  simple  instrument  has  been  found  successful 
in  most  of  the  cases  in  which  the  fingers  alone  proved 
insufficient  ?  One  about  eight  inches  long,  with  a 
fenestrated  curve  at  one  extremity,  to  act  as  a  sort 
of  vectis,  while  the  other  end  is  made  into  a  hook,  as 
shown  in 

Fig.  137. 


^ 


IIow  may  this  instrument  be  used  ?  The  hooked 
extremity  may  be  inserted  into  the  opening  of  the 
flat  or  ring  pessary,  and  be  used  to  assist  in  with- 
drawing it  when  it  has  been  properly  turned  upon  its 
edge,  with  the  point  of  the  finger  applied  on  the  op- 
posite sides  and  upon  the  end  of  the  hook  to  guard  it 
from  injury  to  the  patient.  The  concave  surface  of 
the  curved  extremity  may  be  applied  upon  the  super- 
fice  of  a  globular  pessary,  and  by  the  aid  of  a  finger 
may  be  employed  in  scooping  the  instrument  from  the 
vagina  through  the  vulva. 

PROLAPSUS  OF  THE  UTERUS. 

What  are  we  to  understand  by  prolapsus  of  the 
uterus  ?  Its  precipitation  along  the  canal  of  the 
vagina. 

How  many  degrees  of  prolapsus  are  there  ?  Three. 
First — descent,  where  the  position  is  slightly  altered, 
without  however  any  marked  deviation  of  the  axis  of 
the  uterus,  but  with  the  neck  often  bent  a  little  for- 
ward. Second — precipitation  or  prolapsus,  where 
the  organ  has  descended  low  into  the  vagina,  and  has 
changed  the  direction  of  its  axis,  from  a  correspon- 
30* 


354  PHYSIOLOGY   AND    PATHOLOGY 

dence  with  that  of  the  superior  strait  to  that  of 
the  cavity,  or  even  inferior  strait,  with  its  anterior 
surface  upwards.  Third — procidentia,  or  complete 
prolapsus,  where  the  organ  with  part  or  all  of  its 
appendages,  has  escaped  the  Vulva,  with  its  axis 
corresponding  more  or  less  to  the  axis  of  the  whole 
body. 

ORDINARY  CAUSES  OF  THIS  ACCIDENT. 

What  is  the  most  common  cause  of  prolapsus  ? 
Increased  size  and  weight  of  the  organ,  particularly 
when  accompanied  by  relaxation  or  elongation  of 
the  ligaments,  and  especially  of  the  utero-sacral 
ligaments. 

During  what  period  of  pregnancy  is  the  uterus 
most  likely  to  become  prolapsed  ?  Between  the  first 
and  the  fourth  months,  while  the  organ  is  heavy  and 
yet  not  large  enough  to  be  supported  by  the  bony 
structure  of  the  pelvis  ;  again,  shortly  after  parturi- 
tion, while  the  organ  is  still  large  and  heavy,  and  the 
ligaments  very  much  relaxed  or  elongated. 

What  ligaments  are  most  important  to  the  support 
of  the  uterus  in  situ  ?  The  utero-sacral,  or  posterior 
ligaments  of  the  uterus. 

What  part  does  the  vagina  perform  in  the  support 
of  the  uterus  ?  Probably  none  at  all ;  though  in  this 
respect  obstetric  anatomists  differ  in  opinion. 

What  influence  should  the  knowledge  of  the  risk 
of  accidents  have  upon  our  management  of  puerperal 
females  ?  They,  that  is,  any  others  than  perhaps 
savages  and  very  laborious  women,  should  be  kept  in 
the  horizontal  position  several  days  after  parturition, 
until  the  uterus  may  have  approached  to  its  usual 
size,  and  the  ligaments  have  regained  their  usual  ton- 
icity and  degree  of  contraction. 

What  are  the  exciting  causes  of  prolapsus,  in  single 
or  unimpregnated  women  ?  Great  muscular  exertion, 
which  sometimes  induces  it  in  strong  girls;  sudden  and 
severe  fulls^  constriction  of  the  upper  portion  of  the 


OF   THE   HUMAN    FEMALE.  355 

body,  and  consequent  pressure  upon  the  intestines, 
and  through  them  upon  the  pelvic  viscera,  as  produced 
by  tight  lacing,  severe  straining  to  relieve  constipated 
bowels,  &c. 

What  is  the  ordinary  mode  of  treating  prolapsus 
uteri  ?  That  which  w^as  alluded  to  under  the  head  of 
displacements  generally — astringents  conveyed  into 
the  vagina,  pessaries,  &c. 

What  surgical  means  have  been  devised  for  the 
radical  cure  of  procidentia  uteri  ?  The  removal  of  a 
portion  of  the  mucous  membrane  of  the  posterior  or 
anterior  part  of  the  vagina,  then  bringing  the  edges 
together,  so  that  by  their  adhesion  the  vagina  may  be 
diminished  in  size. 

BANDAGES  AND  COMPRESSES  IN  DISPLACEMENTS  OF 
THE  UTERUS. 

What  is  the  modus  operandi  of  most  of  the  band- 
ages now  in  use  professedly  for  prolapsed  uterus  ? 
They  compress  the  inferior  part  of  the  abdomen,  and 
may  be  properly  called  abdominal  supporters  ;  but  at 
the  same  time,  they  either  force  down  the  small  in- 
testines into  the  cavity  of  the  pelvis  upon  the  uterus, 
or  by  the  firm  pad  placed  in  front  of  the  abdomen, 
and  directly  above  the  pubes,  they  form  such  a 
plane  as  to  cause  the  abdominal  viscera  to  descend 
into,  or  towards  the  pelvis,  when  pressed  upon  from 
above  by  the  diaphragm  and  other  respiratory 
muscles. 

Whaf  is  the  eifoct  of  the  perinaeal  pad  and  straps  ? 
They  contribute  in  conjunction  w^ith  the  circular 
b^nd,  to  subject  the  uterus  to  more  or  less  compres- 
sion, in  consequence  of  its  pressing  up  the  perineum 
to  the  orifice  of  the  uterus. 

With  what  other  displacement  of  the  uterus  may 
prolapsus  be  confounded  ?  With  antero-version,  an- 
tero-flexion,  latero-flexion,  retro-flexion,  and  partial, 
or  even  complete  retroversion. 


356  PHYSIOLOGY   AND    PATHOLOGY 


ANTEVERSION  OF  THE  UTERUS. 

What  is  meant  by  the  term  anteverswn  of  the 
uterus  ?  That  condition  of  the  uterus  in  which 
its  body  and  fundus  are  thrown  forward  against  the 
bladder. 

Is  this  of  frequent  occurrence  ?  It  is  be- 
lieved^ to  be  rare,  and  especially  in  the  unmarried 
female. 

What  symptoms  does  it  produce  ?  Several  of 
those  attendant  upon  prolapsus  and  retroversion,  but 
especially  does  the  patient  complain  of  sense  of  pres- 
sure against  the  bladder  ;  sometimes  this  feeling  is  so 
strong  as  to  have  given  rise  to  the  idea  that  calculus 
existed  in  the  bladder. 

What  attempts  are  to  be  made  to  remove  the 
cause  of  such  distressing  symptoms  ?  The  indica- 
tions are  to  restore  the  displaced  fundus  to  its  proper 
situation,  and  retain  it  if  possible  by  a  well  adjusted 
pessary. 

Does  this  displacement  of  the  uterus  appear  to  ex- 
ert any  influence  over  the  susceptibility  for  impregna- 
tion, or  the  capability  of  the  uterus  to  fulfil  its  office 
as  a  gestative  organ  ?  Since  deviations  from  the  nor- 
ma] positions  of  the  uterus,  generally  more  or  less 
modify  the  susceptibility  for  impregnation,  mostly  di- 
minishing it,  and  sometimes  destroying  it  altogether, 
it  is  probable  that  anteversion  is  often  unfavorable  to 
the  necessary  contact  of  the  two  germs ;  a«d  it  is 
known  that  in  some  cases  the  woman  was  subject  to 
successive  abortions  until  after  the  anteverted  uterus 
had  become  permanently  restored  to  its  proper  rela- 
tion with  the  vagina,  and  other  pelvic  viscera. 

RETROVERSION  OF  THE  UTERUS. 

What  is  meant  by  the  term  retroversion  of  the 
uterus  ?  Retroversion  consists  in  the  turning  of  the 
womb  backwards  into  the  hollow  of  the  sacrum,  so 
that  its  anterior  face  looks  towards  the  concavity  of 


OF    THE    HUMAN    FEMALE. 


357 


that  bone.  While  its  orifice  is  carried  towards  the 
top  of  the  symphysis  of  the  pubes,  so  that  its  inverted 
axis  is  nearly  or  quite  in  the  relation  with  the  axis 
of  the  superior  strait  of  the  pelvis, — its  posterior  face 
is  made  to  come  in  contact  with  the  posterior  surface 
of  the  vagina,  and  its  fundus  and  nearly  all  its  body 
is  depressed  into  the  cul-de-sac  of  the  pelvic  peri- 
tonaeum.    See  fig.  138. 

Fig.  138. 


SYMPTOMS  OF  RETROVERSION  OF  THE  UTERUS. 

What  symptoms  does  this  displacement  usually  pro- 
duce ?  In  nearly  every  respect  they  are  the  same  as 
arise  from  prolapse  of  the  uterus.  In  many  of  the 
cases  the  patient,  with  strong  desires,  can  pass  no 
urine  at  all,  or  at  best  usually  only  a  few  drops  at  a 
time. 

What  circumstances  may  complicate  this  diagnosis 
of  retroversion  ?     The  existence  of  tumors  in  the  sub- 
peritonseal  cellular  tissue,  or  the  descent  of  an  ovary 
into  the  cul-de-sac  below  the  utero-sacral  ligaments. 
PARTIAL  OR  INCOMPLETE  RETROVERSION. 

Is  there  not  a  less  considerable  displacement  of  the 


358  PHYSIOLOGY   AND    PATHOLOGY 

body  of  the  womb  backward,  still  accompanied  by 
many  very  annoying  and  distressing  sensations  ? 
Some  patients  are  afflicted  with  what  has  been  called 
a  partial  retroversion  or  tilting  backwards  of  the  ute- 
rus ;  the  ligaments  are  put  less  considerably  upon 
the  stretch,  and  the  bladder  and  rectum  probably 
less  severely  pressed  upon ;  but  it  would  seem  to  be 
proper  to  regard  this  kind  of  displacement  a  prolapse 
rather  than  a  retroversion  of  the  organ. 

CAUSES  OF  RETROVERSION  OF  THE  UTERUS. 
What  are  some  of  the  prominent  causes  of  retro- 
version of  the  uterus  ?  Too  great  a  distension  of  the 
bladder,  too  severe  and  long  continued  compression 
of  the  abdomen  by  tight  lacing ;  sudden  shocks  to  the 
system  by  falls,  leaping,  dancing,  carrying  great 
weight,  &c. 

TREATMENT  OP  RETROVERSION. 

How  should  you  reduce  retroversion  of  the  non- 
gravid  uterus  ?  Evacuate  thoroughly  as  possible  the 
bladder  and  the  rectum.  Place  the  patient  on  her 
left  side  in  bed,  properly  covered,  with  her  hips  easily 
within  reach,  lubricate  the  index  finger,  and  carry  it 
into  the  genital  fissure  till  it  reaches  the  tumor  in  the 
lower  part  of  the  pelvis,  then  pass  it  slowly  and 
steadily  upwards  if  possible,  till  it  reaches  as  far  as 
the  finger  can  carry  it ;  if  this  attempt  be  successful, 
transfer  the  finger  to  the  os  uteri,  and  as  gently  carry 
it  backwards  till  it  is  restored  to  its  proper  relation 
with  the  axis  of  the  superior  strait. 

If  this  plan  fail,  in  what  other  attitude  of  the  pa- 
tient would  it  be  best  to  repeat  the  attempt  at  reduc- 
tion ?  Request  the  patient  to  place  herself  on  her 
knees  on  the  bed,  and  to  bring  her  chest  as  much  as 
possible  in  contact  with  it. 

What  instruments  have  been  proposed  to  aid  in 
replacing  a  retroverted  uterus  ?  One  by  Professor 
Meigs,  and  two,  a  simple  and  compound  one,  by  Dr. 
H.  Bond. 


OF  THE   HUMAN    FEMALE.  6b\} 

PROFESSOR  MEIGS'  INSTRUMENT. 
"What  does  Dr.  Meigs  in  his  "  Letter  to  his  Class  "  say- 
respecting  the  use  of  instrumental  means  in  replacing 
a  retroverted  uterus  ?  He  there  states,  that  it  some- 
times happens  that  the  surgeon  cannot  succeed  with 
two  fingers  of  the  right  hand,  in  carrying  the  retro- 
verted uterus  so  far  upwards  along  the  course  of  the 
sacrum,  as  to  compel  it  to  rise  above  the  promontor}'" 
of  the  bone,  and  thus  be  set  at  liberty  from  its  im- 
prisonment in  the  lower  basin  of  the  pelvis.  In  order 
to  effect  this,  the  fingers  are  required  to  be  longer 
than  the  usual  length.  By  means  of  the  little  instru- 
ment of  which  fig.  139  is  a  representation,  you  will 

Fig.  139. 


be  enabled  to  carry  it  much  farther  than  with  the 
fingers.  The  instrument  is  made  of  steel,  and  it  is 
conveniently  curved  to  suit  the  form  of  the  back  part 
of  the  excavation.  Conducted  along  the  left  indica- 
tor finger,  to  the  cul-de-sac,  behind  the  vaginal  cer- 
vix, it  may  be  pressed  against  the  overset  womb,  which 
is  readily  pushed  upwards  by  it.  It  is  also  a  conve- 
nient instrument  for  drawing  down  the  cervix  from  the 
pubes ;  that  part  of  the  organ  being  taken  hold  of  by 
the  ring.  The  whole  instrument,  from  the  top  of  the 
ring  to  the  end  of  the  handles,  is  just  eleven  inches 
in  length. 

DR.  HENRY  BOND'S  INSTRUMENT. 
What  are  Dr.  Henry  Bond's  description  and  illus- 
tration of  an  instrument  called  by  hira  the  "  Uterine 
Elevator,"  with  w^hich  he  has  several  times  succeeded 
in  replacing  retroverted   uteri  when  other  means  had 


360  PHYSIOLOGY   ^ND    PATHOLOGY 

failed  ?  The  instrument  consists  of  two  blades — the 
anal  and  the  vaginal — and  of  a  clamp-headed  screw 
and  nut  to  fasten  them  together.  The  anal  blade,  in- 
cluding the  body  and  the  stem,  is  about  9  or  10 
inches  long,  and  made  with  the  curvature  of  a  radius 
of  about  8  inches.  The  body  of  this  blade,  to  which 
belongs  the  handle  of  the  instrument  is  about  3  inches 
long  and  made  square.  Upon  this  the  other  blade 
rests  firmly,  or  slides,  as  circumstances  shall  require. 
The  vaginal  blade,  curved  upon  a  radius  of  about  7 
inches,  has  a  large  groove  two  inches  long,  exactly 
fitted  to  receive  the  body  or  square  part  of  the 
other  blade,  so  as  to  slide  upon  it,  and  to  retain 
a  firm  attachment  by  means  of  the  screw.  The 
groove  has  a  fenestra  through  its  upper  side,  an  inch 
and  a  quarter  long,  and  wide  enough  to  give  passage 
to  the  screw,  when  this  is  placed  longitudinally.  That 
part  of  the  screw  which  is  within  the  fenestra,  when 
the  blades  are  attached  together,  is  square,  so  as  to 
prevent  its  rotation  while  the  nut  is  turned. 

Each  blade  terminates  in  an  ivory  tip.  That  on 
the  anal  blade  is  oval,  an  inch  and  a  half  long  and 
five-eighths  of  an  inch  in  diameter.  The  steel  stem 
of  the  blade  is  bent  so  as  to  be  inserted  into  the 
end  of  the  tip,  and,  at  the  point  of  insertion,  it  has  a 
joint,  allowing  the  tip  (when  it  is  introduced  or  with- 
drawn per  anum)  to  be  thrown  out  so  that  it  pass  in 
and  out  endwise.  The  ivory  is  cut  away  or  grooved 
so  as  to  give  lodgement  to  the  stem,  presenting 
no  salient  point.  The  joint  should  be  made  to 
work  freely ;  and  after  the  tip  has  passed  the  anus, 
it  will  very  readily  assume  its  proper  transverse  posi- 
tion, and  be  as  firm  and  steady  as  if  it  had  been 
riveted  on,  without  any  joint.  The  ivory  tip  on  the 
vaginal  stem  is  oval,  about  ten-eighths  of  an  inch  in 
length  and  five-eighths  in  diameter,  approaching 
nearly  to  a  cylinder  with  spherical  ends  over.  The 
distance  between  the  tips  and  the  junction  of  the 
blades  is  about  six  and  a  half  inches. 


OF   THE   IIUxMAN    FEMALE. 


361 


What  are  the  directions  for  the  manner  of  using  it  ? 
In  using  the  instrument,  detach  the  blades  from 
each  other  ;  introduce  the  anal  tip  into  the  rectum, 
then  the  other  tip  into  the  vagina ;  then  fasten  the 
blades  together  bj  means  of  the  screw.  Be  particu- 
lar to  keep  the  blades  parallel  with  the  axis  of  the  pel- 
vis, and  never  thrust  or  pass  them  forward  with  a 
rash  inconsiderate  haste.  By  means  of  the  slide  of 
one  blade,  upon  the  other,  the  tip  of  the  vaginal 
blade  may  be  placed  higher  or  lower,  as  circumstances 
may  require.  If  the  fundus  uteri  has  sunk  low  be- 
tAveen  the  vagina  and  rectum,  shove  up  the  moveable 
blade,  so  that  the  two  tips  may  be  nearly  on  a  level. 
In  this  position  of  the  tips,  it  is  intended  that  the 
space  between  them  shall  be  only  sufficient  for  the  va- 
gina and  rectum,  without  pressing  them — a  space  not 
exceeding  three-eighths  of  an  inch.  If  the  fundus 
does  not  lie  low,  or  if  the  instrument  has  been  shoved 
up  as  high  as  the  vagina  will  easily  admit,  loosen  the 
screw,  and,  without  allowing  the  vaginal  blade  to  re- 
treat, carry  up  the  anal  blade  in  such  a  manner  as  to 
throw  the  fundus  forward  into  its  normal  position. 
The  instrument  described  may  be  called  the  Double 
Uterine  Elevator,  and  is  adapted  to  the  most  difficult 
obstinate  cases.  Fig.  140,  reppresents  the  double  ele- 
vator, with  the  blades  attached  together. 

Fig.  140. 


362 


PHYSIOLOGY   AND    PATHOLOGY 


What  dees  he  say  about  the  *'  Single  Uterine  Eleva- 
tor?" In  a  large  majority  of  cases  of  retroversion  and 
retroflexion,  the  Single  Uterine  Elevator  sufficiently 
meets  the  indication.  It  consists  of  a  shaft  or  stem  about 
seven  or  eight  inches  long,  Avith  a  suitable  handle  on 
one  end,  and  the  other  end  finished  with  an  ivory  tip 
and  a  joint  like  that  on  the  anal  blade,  just  de- 
scribed. The  stem  should  be  slightly  curved,  so  as  to 
correspond  with  the  axis  of  the  pelvis,  but  the  handle 
and  two  or  three  inches  of  the  stem  next  to  it  should 
be  bent  in  an  opposite  direction,  so  that  when  the  in- 
strument is  introduced  into  the  rectum,  the  handle  of 
it  should  not  interfere  with  the  edge  of  the  finger  in 
the  vagina  at  the  same  time.  It  is  confidently  as- 
serted that  these  single  elevators  will  be  found  more 
efficient  and  more  safe  in  all  these  cases,  where  Dr. 
Simpson's  sound  is  used  to  ascertain  and  rectify  the 
position  of  the  uterus. 

Fig.  141,  represents  the  single  elevator,  with  the 
tip  put  in  a  position  to  be  passed  through  the  anus. 

Fig.  141. 


Fig.  142.  Fig.  142,  exhibits  a  direct  view  of  this 

tip,  and  its  position   after  it  has  passed 
the  sphincter. 

What  treatment  is  usually  required  af- 
ter the  retroverted   uterus   has  been    re- 
stored to  its  proper  position?     In  recent 
cases,  if  the  tone  of  the  pelvic  viscera  and 
the  muscular  system  is  good,  it  is  rarely  necessary  to 


OF   THE    HUMAN    FEMALE.  363 

do  more  than  to  have  the  patient  keep  her  bowels  in 
an  open  state,  empty  her  bladder  seasonably,  and 
avoid  any  active  exercise  for  some  days.  But  under 
almost  any  other  circumstances,  it  will  be  necessary 
for  her  to  wear  a  pessary  to  support  the  organ,  for 
some,  and  perhaps  for  a  long  time. 

RETROFLEXION  OF  THE  UTERUS. 

What  other  peculiar  condition  of  the  uterus'  is 
there,  in  which  the  body  may  be  carried  more  or  less 
backward  ?  Retro-flexion,  in  which  the  uterus  is 
bent  backwards  upon  itself,  in  such  manner  that  the 
mouth  and  a  portion  of  the  neck  may  have  their  usual 
direction,  while  the  fundus,  body,  and  part  of  the 
neck  are  so  bent  backwards  as  to  form  an  angle  with 
the  inferior  portion. 

Is  it  an  affection  easily  to  be  managed  ?  In  gene- 
ral it  is  not ;  it  is  probable  that  it  often  depends  upon 
some  mechanical  cause,  as  the  pressure  of  impacted 
feces  in  the  sigmoid  flexure  of  the  colon,  the  presence 
of  ovarian  or  other  tumors,  &c. 

TUMORS  IN,  OR  SPRINGING  FROM,  THE  UTERUS. 

To  what  part  of  the  uterus  may  the  more  solid 
tumors  be  attached?  Some  spring  from  the  outer 
surface  under  the  peritonasal  coat,  others  on  the 
inner  surface,  and  others  again  have  their  origin  in 
the  substance  proper  of  the  organ. 

What  is  the  character  of  these  morbid  growths  ? 
Sometimes  they  appear  to  be  purely  fibrous,  some- 
times encysted,  that  is,  having  a  fluid,  mucous, 
serous,  puruloid,  or  tubercular  matter  in  the  centre, 
or  in  several  foci,  surrounded  by  a  fibrous  envelope. 
Sometimes  again  they  appear  to  be  entirely  fleshy, 
and  at  some  others  they  are  calcareous  or  osteo- 
sarcomatous. 

NOT  ALWAYS  EASILY  DIAGNOSTICATED. 

Is  the  presence  of  tumors  within  the  uterus,  always 


364  PHYSIOLOGY   AND   PATHOLOGY 

easily  diagnosticated  ?  It  is  sometimes  very  difficult 
to  do  so.  It  has  however  been  observed,  that  in 
many  of  these  cases  the  uterus  seems  to  be  elongated 
to  such  a  degree  as  to  admit  of  the  introduction  of  a 
female  catheter  or  sound  nearly  its  entire  length  into 
its  cavity. 

What  sensations  does  the  patient  usually  expe- 
rience, when  the  tumor  becomes  so  large  as  to  rise 
above  the  superior  strait  of  the  pelvis  ?  The  me- 
chanical inconveniences  which  usually  attend  preg- 
nancy arrived  at  the  same  degree  of  developement — 
the  general  health  may  be  good. 

By  what  means  is  it  to  be  distinguished  from  preg- 
nancy ?     By  auscultation  and  ballottement. 

Is  it  easy  to  discriminate  between  the  existence  of 
tumors  in  the  uterus,  and  those  in  the  ovaria,  or  either 
of  these  from  extra-uterine  fetation  ?  The  diagnosis 
would  be  in  general  difficult. 

What  consequences  may  result  from  inflammatory 
action  in  tumors,  otherwise  quiescent,  and  producing 
little  irritation  ?  When  such  tumors  become  the  seat 
of  inflammation,  more  or  less  rapid  changes  in  their 
structure  may  take  place,  and  serious  results  may 
follow. 

TREATMENT  OF  TUMORS  OF  THE  UTERUS. 

What  treatment  should  in  general  be  employed  ? 
Those  which  are  palliative,  or  simply  discutient,  as 
the  iodine,  cicuta,  tartar  emetic  by  inunction,  &c. 
Attempts  at  removal  by  the  knife  would  in  general 
be  improper. 

By  what  means  may  the  distressing  sense  of  pres- 
sure upon  the  rectum,  and  neck  of  the  bladder  be 
relieved  ?  Occasionally  by  the  use  of  suitable  pessa- 
ries. 

POLYPUS  OF  THE  UTERUS. 
What    name  is  given    to   the  pediculated  tumors 
which  spring  from  the  uterus  ?     Uterine  polypi. 


OF    THE    HUMAN    FExMALE.  365 

What  is  their  general  character  ?  They  are  mostly 
fibrous,  smooth  to  the  touch,  and  very  vascular,  and 
covered  by  a  smooth  membrane.  Some  are  more  of  a 
mucous  character,  and  others  again  are  hard  and 
glandular  in  structure  ;  those  partaking  of  this  parti- 
cular formation,  are  thought  most  frequently  to 
spring  from  the  glandulae  nabothi,  about  the  neck 
of  the  uterus. 

What  portions  of  the  uterus  do  they  generally 
spring  from  ?  From  the  mucous  membrane  of  the 
cavity,  of  the  body,  of  the  neck,  and  from  the  orifice 
of  the  uterus. 

What  symptoms  usually  accompany  uterine  polypi  ? 
They  are  very  various — mostly  they  are  those  of 
a  nervous  character,  none  of  which  are  pathog- 
nomonic. There  is  mostly  leucorrhoea,  sometimes 
dysmenorrhoea,  menorrhagia,  and  almost  always  a 
sensation  of  prolapsus. 

With  what  other  afi'ectlons  of  the  uterus  have 
polypous  tumors  been  confounded  ?  With  preg- 
nancy, with  prolapsus,  with  retroversion,  and  more 
readily  than  with  either,  chronic  inversion  of  the 
uterus. 

How  is  it  to  be  distinguished  from  pregnancy  ?  It 
can  be  confounded  with  pregnancy  only  when  the 
tumor  is  formed  and  retained  within  the  cavity  of  the 
uterus,  but  then  the  constancy  or  frequency  of  the 
discharge,  together  with  the  patulous  orifice  of  the 
uterus,  should  clear  the  diagnosis,  or  at  least  deter- 
mine that  true  pregnancy  does  not  exist. 

IIow  can  we  discriminate  between  polypus  and  pro- 
lapsus, or  retroversion  of  the  uterus  ?  First :  By  the 
character  of  the  tumor  when  it  is  a  prolapsus,  the 
shortening  of  the  vagina,  and  the  recognition  of  the 
descent  of  the  body,  upon  examination  through  the 
rectum  ;  and  also,  the  situation  of  the  os  tincre. 
Second  :  From  retroversion,  because  in  this  sort  of 
displacement,  the  orifice  of  the  uterus,  is  thrown 
31* 


366  PHYSIOLOGY   AND    PATHOLOGY 

strongly  forward,   and   no   pedicle  can  be  recognised 
by  the  finger  in  the  vagina  or  rectum. 

From  what  peculiar  condition  of  the  uterus  is  it 
very  difficult  to  distinguish  it  ?  Chronic  inversion  of 
the  uterus.  The  distinction  must  be  based  partly 
upon  the  history  of  the  affection,  and  the  result  of  a 
careful  physical  examination. 

TREATMENT  OF  POLYPUS  OF  THE  UTERUS. 

What  class  of  uterine  tumors  call  for  and  admit 
of  removal  by  surgical  means  ?  Those  which  are  pedi- 
culated,  as  polypus,  and  as  cauliflower  excrescences. 

Which  is  the  better  and  the  safer  mode  of  removal, 
by  the  knife  or  scissors,  or  by  the  ligature  ?  In  a 
large  majority  of  cases  by  the  ligature. 

Is  it  always  easy  to  cast  a  ligature  upon  a  polypus 
whose  pedicle  is  within  the  os  uteri  high  up  in  the 
pelvis  ?  The  embarrassment  is  such  that  very  many 
devices  have  been  proposed  to  enable  the  surgeon  to 
accomplish  the  operation,  and  it  is  probable  that  the 
double  canula  of  Gooch  is  the  most  useful. 

INFLAMMATION  OF  THE  GENITAL  ORGANS. 

How  are  we  to  study  or  regard  inflammatory  affec- 
tions of  the  organs  of  generation  in  the  female  ? 
In  relation  to  the  tissue  which  is  affected.  Thus, 
in  inflammation  of  the  mons  veneris  the  effects 
of  the  disease  are  modified  by  the  density  of  the 
structure ;  hence  when  it  suppurates,  the  pus  being 
bound  down,  burrows  more  or  less  as  though  under  a 
fascia. 

In  what  respect  does  inflammation  of  the  vulva 
differ  from  that  of  the  mons  veneris  ?  This  structure 
being  much  less  firm,  great  tumefaction  from  sanguine 
congestion  and  edema  are  apt  to  follow.  Suppura- 
tion also  takes  place  more  readily. 

With  what  is  common  inflammation  of  the  vulva 
often  complicated  ?  With  an  aphthous  eruption,  as 
seen  sometimes  in  the  mouths  of  young  children. 


OF   THE    HUMAN    FEMALE.  3GT 

What  class  of  females  are  subject  to  inflammation 
of  the  uterus  ?  It  is  liable  to  occur  in  single  as  well 
as  married  women,  and  in  the  pregnant  and  non-preg- 
nant condition. 

What  is  it  called  when  it  attacks  the  substance  of 
the  uterus  ?     Hjsteritis,  or  metritis. 

HYSTERITIS  OR  METRITIS. 

To  what  grades  of  inflammation  is  this  organ  lia- 
ble ?  As  most  others,  to  acute  and  chronic  inflam- 
mation. 

What  are  some  of  the  causes  of  metritis  or 
hysteritis  ?  Blows,  falls,  sympathetic  irritation  in 
oj:her  organs,  violence  to  the  uterus  during  partu- 
rition, &c.  The  causes  which  produce  dysmenor- 
rhoea,  also  sometimes  give  rise  to  metrit's.  The 
uterus  may  also  become  inflamed  from  the  applica- 
tion of  syphilitic  virus  applied  directly  to  it,  or  it 
may  have  been  indirectly  communicated  along  the 
vagina. 

To  what  other  specific  inflammation  is  the  uterus 
liable  ?     To  gout  or  rheumatism. 

SYMPTOMS  OF  METRITIS. 

What  symptoms  accompany  metritis  ?  Chill, 
fever,  pain  in  the  back,  but  particularly  in  the  hypo- 
gastrium.  The  bladder  is  irritated  and  little  urine 
can  be  retained,  great  pain  is  experienced  in  any 
attempt  at  motion  ;  when  the  attack  is  severe  the 
patient  is  obliged  to  lay  down  upon  the  back,  have 
the  legs  drawn  up  to  take  off"  all  pressure  from 
the  affected  part.  In  the  milder  forms  there  is  less 
pain,  and  little  or  no  sympathetic  sign  of  the  local 
aff'ection. 
^  What  condition  of  the  parts  is  found  on  physical 
examination  ?  Vagina  and  uterus  hot,  the  uterus 
thickened,  hard,  congested,  heavy,  and  painful  to 
the  touch. 


368  PHYSIOLOGY   AND    PATHOLOGY 

MODES  OF  TERMINATION  OF  METRITIS. 

What  are  the  varieties  of  termination  of  metritis  ? 
Resolution,  abscess,  chronic  inflammation,  induration, 
and  ramollissement  or  softening. 

What  is  the  general  character  of  induration  of  the 
uterus  ?  First :  The  whole  uterus,  with  its  neck,  is 
large.  Second  :  The  organ  maj  frequently  be  felt 
above  the  pubes,  regular  in  shape,  and  little  if  at  all, 
sensitive  to  the  touch.  Third  :  Balanced  upon  the 
point  of  the  finger  it  feels  heavy,  and  by  this  weight 
in  the  vagina  it  causes  the  sensation  of  prolapsus. 

Does  this  induration  pass  speedily  into  any  other 
form  of  disease  ?  It  often  remains  stationary  for  a 
long  time,  even  during  the  balance  of  life  without 
injury  to  the  patient. 

Is  it  always  free  from  morbid  sensibility,  when  in 
this  indurated  state  ?  It  is  not ;  on  the  contrary,  it 
sometimes  remains  irritable  for  days,  weeks,  and  even 
years,  and  this  irritation,  as  has  been  said  already,  is 
sometimes  kept  up  by  the  displacement  of  the  organ, 
whether  it  be  prolapsed,  or  retroverted. 

Are  the  functions  of  menstruation  and  reproduc- 
tion necessarily  interfered  with  by  the  occurrence  of 
induration  of  the  uterus  ?  Patients  may  continue  to 
menstruate,  but  if  they  become  pregnant,  they  will 
be  likely  to  abort. 

Is  ramollissement  or  softening  of  the  substance  of 
the  uterus  usually  extended  to  the  entire  organ  ? 
It  is  perhaps  altogether  a  rare  mode  of  termination 
of  inflammation,  but  when  it  does  so  occur,  it  is  more 
frequently  confined  to  a  part,  than  extended  to  the 
whole  organ. 

ABSCESS  OF  THE  UTERUS. 
What  parts  of  the   uterus  may  be  the  seat  of  ab-  ^ 
acess  ?     Sometimes   it  occurs  in  the   substance,  and 
points  towards  the  cavity  of  the  abdomen  or  pelvis, 
sometimes  it   opens   upon   the  inner  surface   of  the 
uterus. 


OF   THE   HUMAN    FEMALE.  869 

When  the  abscess  points  towards  the  external  sur- 
face of  the  uterus,  what  process  is  usually  com- 
menced ?  The  serous  membrane,  viz.  :  the  periton- 
aeum, usually  suffers  from  local  inflammation  which 
results  in  adhesion,  and  thus  a  cyst  is  formed  which 
contains  the  effused  pus  until  ulceration  is  effected 
into  the  rectum,  and  the  matter  passed  off  per  anum ; 
or  the  coats  of  the  bladder  are  perforated  and  the 
pus  escapes  with  the  urine,  or  an  opening  is  made 
between  the  vagina  and  bladder,  or  between  the 
uterus,  vagina,  and  rectum ;  or  lastly,  and  least 
frequently,  a  perforation  is  made  through  the  cyst 
into  the  cavity  of  the  abdomen,  and  fatal  peritonitis 
is  induced. 

What  is  the  prognosis  of  abscess  in  the  uterus  ? 
Mostly,  unless  the  abscess  open  mto  the  cavity  of  the 
peritonaeum,  life  may  be  preserved,  though  the  pa- 
tient's health  may  remain  a  long  time  impaired. 

TREATMENT  OF  ACUTE  METRITIS. 

What  treatment  is  appropriate  to  acute  metritis  ? 
One  strictly  antiphlogistic,  as  venesection,  saline  ca- 
thartics, antimonials,  local  blood-letting,  low  diet, 
perfect  rest,  and  some  active  revulsives,  as  fomenta- 
tions, blisters,  &c.,  &c. 

What  is  to  be  said  respecting  the  use  of  cold  or 
astringents  ?  That  though  useful  in  some  stages  of 
the  disease,  they  afe  entirely  inadmissible  in  rheuma- 
tic or  gouty  constitutions. 

If  the  inflammation  terminate  in  induration,  how 
is  it  to  be  treated  ?  Attempts  are  to  be  made  to 
discuss  it  by  the  use  of  remedies  believed  to  act  pow- 
erfully as  discutients,  as  small  and  repeated  doses  of 
mercury,  in  the  form  of  calomel,  blue  pill,  or  corro- 
sive sublimate.  By  many  the  cicuta  has  been  thought 
to  act  in  this  w^ay,  and  latterly  the  Lugol's  solution 
of  iodine,  in  doses  of  from  eight  to  ten  drops, 
three  times  a  day,  has  had  some  reputation  for  this 
purpose. 


370  PHYSIOLOGY   AND    PATHOLOGY 

Is  it  necessary  to  confine  the  patient  to  her  bed  for 
the  discussion  of  the  induration  ?  Freedom  from  ex- 
citement should  be  secured  to  her,  but  often  she  may 
be  permitted  to  move  about  while  under  treatment, 
provided  the  heavy  organ  be  supported  upon  a  pessary. 

What  train  of  symptoms  would  indicate  the  termi- 
nation in  suppuration  ?  A  continuance  of  the  pain, 
with  constitutional  irritation,  together  with  a  sense  of 
throbbing  in  the  part. 

What  particular  portion  of  the  uterus  is  most  liable 
to  inflammation  ?  That  part  which  dips  into  the  va- 
gina, or  the  neck  and  mouth  of  the  uterus. 

What  are  some  of  thQ  numerous  causes  of  inflamma- 
tion of  this  part  of  the  uterus?  1.  Extension  of  in- 
flammation from  the  mucous  membrane  of  the  vagina — 
hence  it  is  often  connected  with  vaginitis.  2.  It  is 
sometimes  caused  by  the  os  tincne  dropping  down  into, 
and  becoming  strangulated  in  the  orifice  of  a  flat  pes- 
sary ;  mechanical  shocks,  as  violence  in   coition,  &c. 

What  symptoms  usually  accompany  inflammation  of 
the  neck  of  the  uterus  ?  They  are  similar  to  those  of 
mild  metritis,  as  pain  in  the  back,  heat  and  weight  in 
the  pelvis,  &c. 

What  evidence  can  we  have  that  the  inflammation  is 
confined  to  the  neck,  and  does  not  involve  the  body  ? 
The  neck  is  found  tumid,  and  the  body  not  so,  when 
examined  by  the  touch. 

What  are  some  of  the  terminations  of  inflamma- 
tion of  the  neck  of  the  uterus  ?  In  resolution,  in  in- 
duration, in  scirrhus,  in  ulceration  both  simple  and  ma- 
lignant. 

ULCERATION  OF  THE  UTERUS. 

How  are  we  to  distinguish  simple  from  syphilitic  ul- 
ceration of  this  part?  Simple  ulceration  is  said  to  have 
smooth  regularly  defined  edges,  while  those  of  the  spe- 
cific character  have  irregular  margins. 

What  varieties  of  simple  ulcerations  may  affect  the 
neck  ?     1.  Simple  ulceration  of  the  mucous  membrane, 


OF   THE    HUMAN    FEMALE.  371 

resembling  an  abrasion  of  the  mucous  surface.  2.  One 
in  which  there  are  deposites  of  small  patches  of  lymph, 
as  aphthae,  &c. 

How  is  the  corroding  ulcer  to  be  distinguished  from 
either  of  these  varieties  ?  By  the  fact  that  it  digs  out 
the  internal  surface  of  the  mouth  and  neck  of  the 
uterus  and  is  constantly  extending  by  the  process  of 
ulcerative  absorption. 

Can  simple  ulcerations  always  be  recognized  by  the 
touch  ?  They  cannot ;  it  is  rarely  safe  to  rely  upon 
the  touch  for  a  knowledge  of  their  character. 

BEST  MODE  OF  RECOGNITION— SPECULUM. 

How  then  are  they  to  be  recognized  ?  By  means 
of  a  speculum  or  well  adjusted  tube,  passed  so  adroitly 
into  the  vagina,  as  to  enable  the  eye  of  the  practitioner 
to  see  the  part  affected,  and  thus  derive  more  accu- 
rate knowledge  respecting  it. 

AYhat  variety  of  speculums  are  there,  and  of  what 
materials  are  they  composed  ?  They  are  made  of  glass, 
or  of  some  of  the  metals.  Some  are  complete  tubes, 
either  cylindrical,  or  somewhat  conical — consisting  of 
a  single  piece — such  are  composed  of  glass,  pewter,  or 
the  mixed  metals.  Others  are  so  divided  that  they 
operate  with  handles  upon  a  hinge,  and  resemble  a  tube 
cleft  longitudinally,  with  a  pivot  so  adjusted  that  the 
two  extremities  of  the  blades  can  be  more  or  less  wide- 
ly separated.  Others  are  so  constructed  as  to  consist 
of  three  equal  blades,  so  adapted  as  to  move  upon 
each  other,  and  thus  to  be  passed  into  the  vagina  while 
folded  up,  and  afterwards  expanded,  to  bring  the  ori- 
fice of  the  uterus  into  view. 

WhTch  variety  of  those  now  in  use  is  probably  best 
adapted  to  most  purposes  for  which  the  instrument  is 
required  ?  The  quadrivalve  instrument,  which  is  so 
constructed  that  it  enters  the  vagina  in  a  small  com- 
pass, yet  it  is  capable  of  great  expansion  when  neces- 
sary, by  compressing  the  two  handles. 

How  is  the  speculum  to  be  introduced  ?     When   no 


372  PHYSIOLOGY   AND    PATHOLOGY 

great  precision  in  the  examination  is  requisite,  the  pa- 
tient may  be  placed  on  her  left  side,  close  to  the  edge 
of  the  bed — or  what  is  to  be  preferred,  she  may  be 
placed  on  her  back,  with  her  feet  resting  at  the  end 
of  the  bed,  and  the  breech  brought  down  to  her  heels. 
If,  however  any  careful  investigation  of  the  condition 
of  the  OS  tincse  is  necessary,  it  becomes  almost  indis- 
pensable that  the  hips  should  be  brought  upon  the  edge 
of  the  bed,  elevated  by  a  pillow  or  some  suitable  pad- 
ding, while  the  feet  are  extended  upon  chairs  or  suit- 
able supports  outside  of  the  bed.  'The  patient's  limbs 
should  be  properly  covered  with  drawers,  and  over  all 
should  be  placed  a  sheet  or  blanket,  having  in  the 
central  seam  an  orifice  ripped  sufiiciently  large  to 
receive  the  instrument  as  far  as  to  the  handles.  The 
examinator  is  then  to  be  seated  or  stationed  between 
the  knees  of  the  patient,  while  the  instrument,  well 
lubricated,  is  to  be  passed  by  one  hand  through  the 
orifice,  as  far  as  to  the  handles  or  base.  The  vulva 
is  also  to  be  well  lubricated  by  the  other  hand,  one  or 
two  fingers  of  which  are  to  be  passed  into  the  orifice 
of  the  vagina,  to  press  back  the  perin^eum.  As  soon 
as  the  posterior  commissure  of  the  vulva  is  put  sufii- 
ciently upon  the  stretch,  the  point  of  the  instrument 
should  be  carried  down  upon  the  back  of  these  fingers, 
which  should  thus  form  a  plane,  along  which  the  em- 
bout,  or  rounded  w^ooden  extremity  of  the  speculum, 
can  be  guided  over  the  posterior  surface  of  the  vagina. 
This  done,  the  fingers  are  to  be  withdrawn,  and  that 
hand  called  to  aid  the  other  in  cautiously  passing  the 
speculum  onwards  in  the  axis  of  the  vagina  to  the 
cul-de-sac  behind  the  uterus.  The  handles  may  then 
be  carefully  pressed  towards  each  other,  when  the 
emboutj  becoming  disengaged,  is  forced  out  by  the 
spring  contrived  for  the  purpose,  and  thus  leaves  the 
upper  portion  of  the  vagina  accessible  to  the  eye  of 
the  examinator. 

What  kind  of  light  is  best  adapted  to  the  purpose 
of  such  examinations?      Clear  daylight  is  to  be  pre- 


OF   THE   HUMAN    FEMALE.  3T3 

ferred :  but  a  bright  moveable  ligbt,  such  as  a  free 
burning  lamp  or  candle  will  mostly  answer  the  pur- 
pose very  well. 

What  obstructions  may  prevent  the  ready  discovery 
of  the  state  of  the  parts  ?  A  greater  or  less  quantity 
of  tenacious  mucus,  or  even  coagulated  blood,  may 
be  attached  to  the  surface  of  the  os  tincse.  This 
must  be  wiped  off  by  a  mop  made  of  fine  sponge  or 
charpie,  or  washed  away  by  a  detergent  injection.  . 

TREATMENT  OF  ULCERS  OF  THE  OS  TINCiE. 

What  is  the  proper  treatment  of  ulcers  of  the  os 
tincae?  Depletory,  while  any  marked  inflammatory 
action  exists — then  astringents,  and  for  the  mucous 
ulcerations  the  nitrate  of  silver,  either  in  substance 
on  a  port  caustique,  or  in  proper  solution,  and  applied 
by  means  of  a  camel's  hair  pencil. 

Is  it  essential  that  the  patient  should  be  kept  at 
rest  during  the  treatment  ?  If  possible,  the  patient 
should  be  kept  at  rest,  and  pressure  should  as  much 
as  possible  be  taken  from  the  uterus.  Where,  however, 
quietness  is  impracticable,  the  patient  should  have  the 
ulcerated  surface  of  the  uterus  isolated  from  the  mu- 
cous membrane  of  the  vagina,  by  the  use  of  a  properly 
adjusted  pessary.  The  dressings  or  washings  can 
then  be  applied  with  better  effect. 

Are  dressings  to  the  os  tinc^e  of  easy  application  ? 
They  can  rarely  be  properly  applied  unless  through 
the  speculum,  previously  introduced,  to  bring  the  af- 
fected part  into  view. 

Is  it  important  that  an  accurate  distinction  be  made 
between  pure  inflammation  of  a  part,  and  irritation 
and  disorders  of  function  merely  ?  It  is  highly  im- 
portant, as  the  therapeutic  indications  are  essentially 
different  in  many  of  these  cases. 

MALIGNANT  ULCERATIONS  OF  THE  UTERUS. 
Wliat  is  meant  by  the  term  phagedenic  or  corrosive 
ulcer  of  the  mouth  or  neck  of  the  womb  ?     That  va- 
32 


874  PHYPTOLOGY    AND    PATHOLOGY 

riety  of  ulcers  which  is  constantly  extending  by  the 
progress  of  ulcerative  absorption. 

Is  it  proper  to  regard  this  as  always  malignant  and 
incurable  ?  It  is  mostly  sufficiently  malignant  in  its 
character  to  produce  serious,  and  generally  fatal  in- 
roads upon  the  constitution,  but  it  is  sometimes  amen- 
able to  appropriate  remedies. 

In  what  class  of  females  does  it  usually  occur  ?  In 
those  of  a  lymphatic  temperament,  and  who  have 
passed  the  menstruating  period  of  life  in  most,  but 
not  in  all  cases. 

Is  its  existence  generally  recognized  early  after  its 
commencement  ?  As  it  is  usually  not  attended  with 
very  severe  pain,  the  patient  ascribes  the  discharge 
which  attends  it  to  too  frequent  a  menstruation,  or  if 
she  be  passed  this  period  of  life,  she  thinks  menstrua- 
tion has  returned. 

What  sensations  are  usually  experienced  by  these 
who  have  this  disease  ?  Principally  a  sense  of  weight, 
bearing  down,  as  occurs  in  prolapsus  or  other  displace- 
ment. 

DIAGNOSIS  OF  MALIGNANT  ULCER. 

What  condition  of  the  uterus,  &c.,  is  to  be  recog- 
nized by  the  finger  in  the  touch  in  such  cases  ?  The 
circumference  of  the  neck  is  found  enlarged,  and  the 
orifice  very  considerably  so — it  seems  to  be  infundi- 
bulated  or  dug  out — sometimes  the  fingers  will  pass 
readily  to  the  internal  os  uteri. 

Is  the  body  of  the  uterus  moveable  or  fixed  in  these 
cases  ?  It  is  usually  quite  free  and  moveable — some- 
times it  is  a  little  engorged.  The  neck  only  or  the 
internal  surface  being  implicated. 

Can  an  accurate  diagnosis  be  obtained  by  the  touch 
alone  ?  No,  the  sense  of  sight  through  the  medium 
of  the  speculum  becomes  necessary  to  recognise  to  the 
fullest  extent  the  alterations  which  have  taken  place. 

What  influence  does  this  affection  exert  upon  the 
constitution  of  the  patient?     Although   it  is  usually 


OF   THE    HUMAN   FEMALE.  375 

attended  with  very  little  pain,  yet  sooner  or  later  the 
patient  becomes  reduced  to  a  state  of  great  feeble- 
ness and  prostration.  The  absorption  of  the  vitiated 
secretion  produces  hectic  fever,  great  emaciation,  fol- 
lowed by  edema,  &c. 

What  parts  l3ecome  subsequently  involved  in  the 
erosive  process  which  is  going  on  ?  The  bladder,  or 
rectum,  or  both,  become  opened  so  that  the  urine  es- 
capes by  the  vagina ;  or  in  the  event  of  the  rectum 
being  ulcerated,  the  feces  pass  by  the  same  route. 

TREATMENT  OF  MALIGNANT    ULCERS    OF  THE    UTERUS. 

What  precautionary  measures  are  to  be  adopted  to 
prevent  an  aggravation  or  rapid  extension  of  the  dis- 
ease ?  The  constant  use  of  detergent  injections  into 
the  vagina,  and  perhaps  into  the  uterus  itself,  with 
a  view  to  remove  as  effectually  as  possible  all  the  mat- 
ter as  fast  as  secreted. 

What  local  medicines  may  be  used  ?  Those  of  an  as- 
tringent character  have  generally  been  thought  pro- 
per, after  a  due  ablution  of  the  surfaces  with  bland 
mucilages,  or  simple  warm  water ;  thus  the  sulphate 
or  acetate  of  zinc,  in  the  proportion  of  one,  two,  or 
three  grains  to  the  ounce  of  water,  may  be  thrown  up 
by  a  syringe,  or  carried  upon  charpie,  through  the 
speculum  by  some  suitable  instrument.  The  solution, 
or  solid  nitrate  of  silver  and  various  other  escharotics 
have  also  been  used  in  such  cases. 

Is  it  proper  to  rely  upon  local  treatment  alone  ?  It 
will  be  highly  important  to  attend  to  all  the  hygienic 
measures  which  improve  the  general  health. 

In  regard  to  the  use  of  injections  into  the  cavity 
of  the  uterus,  how,  and  by  what  means  should  they 
be  introduced?  Unless  there  be  a  reliable  nurse  in 
attendance  the  practitioner  should  always  apply  them, 
and  that  if  possible  two  or  three  times  a  day.  The 
mucilage  of  flaxseed,  slippery  elm,  pith  of  sassafras, 
starch  or  barley,  should  be  carefully  strained,  and 
then  conveyed  through  a  gum  elastic  catheter,  the 


376  PHYSIOLOGY    AND    PATHOLOGY 

eyelet  end  of  which  should  be  first  carefully  introduced 
upon  the  point  of  the  finger  into  the  cavity  of  the 
uterus,  and  so  retained  by  the  hand  of  the  patient  or 
a  proper  assistant,  that  it  be  not  driven  forcibly 
against  the  walls  of  the  uterus  when  adapting  the  pipe 
of  the  syringe  to  it :  or  a  silver  tube  curved  into  the 
proper  shape  may  be  substituted,  and  to  this  the  sy- 
ringe when  charged  may  be  so  fitted  as  to  pass  up  the 
whole  contents  into  the  cavity  of  the  uterus.  This 
operation  with  whatever  kind  of  instrument,  should  be 
conducted  with  great  care,  as  not  only  the  instrument 
improperly  introduced  may  do  much  injury,  but  there 
is  some  danger  of  forcing  the  fluids  along  the  fallopian 
tubes  into  the  cavity  of  the  peritonaeum,  and  thus 
causing  fatal  peritonitis. 

CANCER  OF  THE  UTERUS. 

Is  cancer  of  the  uterus  a  very  common  disease  ? 
In  this  country  it  is  believed  really  to  be  one  of  very 
rare  occurrence,  though  there  are  many  aifections  of 
the  uterus  which  are  ascribed  to  cancer,  and  yet  are 
not  carcinomatous. 

What  portion  of  the  uterus  is  most  liable  to  be  at- 
tacked with  cancer  ?     The  neck. 

What  is  the  usual  mode  of  attack  of  cancer  ?  The 
parts  become  the  seat  of  irregular  induration  of  a 
scirrhous  character,  being  more  nodulated,  harder  and 
more  dense  and  painful  than  simple  induration ;  one 
lip  is  mostly  sensibly  larger  than  the  other. 

What  is  usually  observed  in  regard  to  the  vagina  in 
these  cases  ?  That  it  is  more  or  less  shortened,  and 
sometimes  adherent  to  adjacent  parts.  The  same  may 
be  said  of  the  uterus,  which  is  usually  found  im- 
moveable, being  bound  down  to  the  blader,  or  rectum, 
or  both. 

What  is  subsequently  observed  in  respect  to  the 
march  of  the  disease?  Sooner  or  later,  corrosive  ul- 
ceration with  hemorrhage  from  the  surface  which  is 
sometimes   studded    by  a   fungus  growth  takes  place. 


OF   THE    HUMAN   FEMALE.  377 

The  patient  also  experiences  deep  seated  lancinating 
pain,  (which  is  generally,  though  not  uniformly  pa- 
thognomonic of  cancer,)  and  after  a  time  the  ner- 
vous system  suffers  severely,  while  sooner  or  later 
the  aspect  of  the  patient  changes :  she  loses  the 
solidity  of  muscular  and  cellular  tissue,  she  may  pre- 
viously have  possessed,  and  substitutes  for  it  a  straw 
colored  surface,  with  more  or  less  edema  of  the  whole 
cellular  membrane, 

TREATMENT  OF  CANCER  OF  THE  UTERUS. 

What  should  be  the  treatment  of  cancer  of  the  ute- 
rus ?  At  the  very  incipient  stage,  it  should  be  anti- 
phlogistic ;  after  it  has  made  some  progress,  we  can 
do  no  more  than  palliate  by  keeping  the  system  con- 
stantly under  the  influence  of  cicuta,  hyosciamus,  &c., 
though  sooner  or  later,  we  are  generally  compelled  to 
use  opium  in  some  form  or  preparation,  in  gradually 
increasing  doses,  to  keep  up  a  degree  of  narcotism. 
By  these  means,  the  action  of  the  disease  is  sometimes 
arrested  in  its  early  stage,  and  its  development  re- 
tarded for  a  greater  or  less  length  of  time.  When 
ulceration  occurs,  the  same  care  should  be  taken  to 
wash  away  the  vitiated  secretions. 

What  is  to  be  said  respecting  the  propriety  of  am- 
putating the  neck  of  the  uterus  ?  Although  this  ope- 
ration has  been  frequently  practised  in  Europe,  in 
cases  of  real  or  supposed  cancer,  the  recorded  results 
are  not  sufficiently  favorable  in  cases  of  true  carci- 
noma as  to  gain  our  approbation  for  the  practice. 
The  diagnosis  of  the  disease  while  strictly  confined  to 
the  inferior  portion  of  the  neck,  is  not  sufficiently  clear 
to  justify  an  indiscriminate  resort  to  it ;  and  further, 
when  it  has  become  clearly  developed,  the  parts  above 
the  reach  of  the  knife  are  so  often  invaded  by  the 
same  disease,  that  little  or  no  benefit  could  arise 
from  the  cutting  away  of  a  portion  only  of  the  dis- 
ease. 

32* 


378  PHYSIOLOGY    AND    PATHOLOGY 

CAULIFLOWER   EXCRESCENCE  OF  THE  UTERUS. 

What  other  morbid  formations  are  liable  to  take 
place  in  or  about  the  uterus  ?  Cauliflower  excres- 
cence, fibrous  tumors,  polypi,  moles,  and  osteo-sarco- 
matous  tumors. 

What  is  the  nature  of  cauliflower  excrescence  ?  It 
appears  to  be  composed  of  a  tissue  of  vessels  bound 
together  by  slight  attachments  of  cellular  membrane, 
and  covered  by  a  smooth  but  very  fragile  envolope  of 
the  same  character  ;  to  the  touch  it  feels  like  a  fungus 
or  cauliflower,  whence  the  English  name.  When  ex- 
posed to  the  eye,  it  displays  a  bright  arterial  color. 

What  is  its  general  texture  ?  Very  slight,  it  is 
ruptured  by  slight  pressure,  the  touch  of  a  finger,  or 
the  point  of  a  syringe,  or  even  the  contractions  of 
the  vagina,  or  pressure  of  the  perinaeum  upon  it ; 
hence  it  readily  pours  out  a  great  deal  of  serum  and 
very  often  some  blood,  and  thus  drains  the  patient. 
In  some  instances,  its  texture  is  more  firai. 

What  proofs  have  we,  that  it  consists  almost  en- 
tirely of  vessels  of  the  most  delicate  texture  ?  Im- 
mediately after  death  it  is  found  completely  collapsed, 
with  scarcely  a  vestige  of  its  character  w^hile  living, 
and  when  strangulated  by  a  ligature,  the  same  thing 
is  observed.  When  the  ligature  comes  away,  there 
is  usually  only  a  half  putrid  membranous  mass  de- 
tached by  it. 

What  is  its  usual  point  of  origin  ?  The  neck  or 
orifice,  though  sometimes  the  cavity  of  the  body  of  the 
uterus. 

What  period  of  life  is  most  incident  to  it  ?  Though 
of  rare  occurrence,  it  may  attack  at  any  period  of 
married  or  single  life. 

What  influence  does  it  exert  upon  the  health  of  the 
patient  ?  The  constant  drainage  to  which  she  becomes 
subject,  sooner  or  later,  renders  her  anemic,  gives  her  a 
pallid,  or  straw  colored  appearance  :   it  is  also  usually 


OF   THE   HUMAN    FEMALE.  379 

accompanied  by  more  or  less  edema,  and  other  evi- 
dences of  debility. 

With  what  other  diseases  may  this  cauliflower  excres- 
cence be  confounded  ?  With  polypus,  and  the  fungus 
which  sometimes  springs  from  a  cancerous  base  in  the 
uterus. 

What  is  the  prognosis  of  cauliflower  excrescence  ? 
It  is  generally  unfavorable. 

What  treatment  has  been  proposed  and  adopted  for 
it  ?  Astringents  of  various  kinds  ;  and  in  using  these 
to  avoid  the  rupture  of  the  surface  of  the  tumor  it 
is  proposed  to  have  the  patient's  hips  elevated,  and 
then  pour  the  fluid  into  the  vagina  from  a  suitable 
vessel. 

TREATMENT  OF  CAULIFLOWER  EXCRESCENCE 
OF  THE  UTERUS. 

Has  any  surgical  treatment  ever  been  resorted  to, 
for  its  removal  ?  The  ligature  has  been  applied  to  its 
base  for  that  purpose,  and  its  removal  has  thus  been 
accomplished.     The  os  uteri  has  also  been  ablated. 

What  should  be  applied  to  the  base  of  the  tumor 
after  removal,  to  prevent  its  return  ?  The  nitrate  of 
silver,  or  what  Churchill  has  regarded  better,  the 
butter  of  antimony,  through  a  speculum. 

PHYSOMETRA. 

What  do  you  mean  by  the  term  physometra  ?  Tym- 
panitis uteri,  or  a  distension  of  the  uterus  by  a  quan- 
tity of  air  supposed  to  be  secreted  within  its  cavity. 

Does  the  mucous  membrane  of  the  vagina  probably 
ever  secrete  air  also  ?  It  is  believed  that  it  sometimes 
does,  as  some  females  have  these  discharges  of  air  per 
vaginam  only  when  in  the  unimprcgnated  state,  and 
others  when  pregnant. 

Is  it  ever  attended  with  any  serious  consequences  ? 
Not  when  it  passes  off"  readily,  which  it  does  do  some- 
times with  considerable  noise ;  but  when  it  is  confined 
within  the  cavity  of  the  uterus,  the  patient  suffers 
more  or  less  from  distension. 


380  PHYSIOLOGY    AND    PATHOLOGY 

Upon  what  condition  of  the  system,  does  it  depend? 
Some  suppose  it  dependent  upon  a  low  degree  of  in- 
flammation of  the  mucous  membrane ;  others  ascribe 
it  to  some  peculiar  condition  of  the  nervous  system, 
which  presides  over  the  secretory  processes. 

How  is  the  distension  of  the  uterus  from  this  cause, 
to  he  distinguished  from  pregnancy?  By  percussion, 
auscultation,  and  ballottement :  1.  Percussion  pro- 
duces a  resonance  which  cannot  be  perceived  in  preg- 
nancy. 2.  Auscultation  in  this  case,  cannot  detect 
the  sound  of  the  fetal  heart,  &c.  3.  Ballottement, 
cannot  recognise  the  existence  of  a  body  moveable  in 
a  fluid,  within  the  cavity  of  the  uterus. 

TREATMENT  OF  PHYSOMETRA. 

What  treatment  is  to  be  used  in  these  cases  ? 
There  is  no  specific  remedy  known  for  this  affection :  if 
the  air  do  not  pass  *off"  under  contraction  of  the  ute- 
rus, or  by  the  shock  of  the  abdominal  muscles,  by 
coughing,  or  otherwise,  it  may  be  necessary  to  dilate, 
or  perforate  the  os  uteri,  and  allow  the  air  to  pass 
through  a  catheter,  or  canula ;  after  which,  it  has 
been  proposed  to  apply  to  the  inner  surface  of  the 
uterus,  solution  of  nitrate  of  silver,  or  some  prepara- 
tion of  iodine,  &c.,  with  the  view  to  alter  the  con- 
dition of  the  surface  which  gives  rise  to  this  secretion  : 
particular  regard  should  be  had  to  the  healthy  condi- 
tion of  the  general  system. 

HYDROMETRA. 

What  do  you  mean  by  the  term  hydrometra? 
Dropsy  of  the  uterus,  from  an  accumulation  of 
serous,  albuminous,  or  muco-purulent  fluid,  within  its 
cavity. 

Is  this  condition  easily  diagnosticated  ?  It  is  not, 
being  easily  confounded  with  pregnancy, — having  a 
similarity  of  sympathetic  signs,  though  the  stomach 
is  said  usually  to  sympathize  less  than  in  pregnancy. 

What  physical  examination  is  best  adapted  to  clear 


OF   THE    HUMAN    FEMALE*  381 

the  diagnosis  ?  Ballottement,  by  which  the  uterus  is 
found  to  contain  a  fluid,  but  having  nothing  moveable 
suspended  within  it.  Auscultation,  moreover,  detects 
no  sounds  of  the  fetal  heart. 

What  treatment  is  proper  for  hydrops  uteri,  or  hy- 
drometra  ?  A  general  diuretic  treatment  might  be 
somewhat  useful,  but  it  is  mostly  necessary  to  perfo- 
rate the  uterus,  by  a  stilet  or  catheter  in  its  orifice, 
or  pass  a  trochar  and  canula  into  some  part  of  the 
neck  which  can  be  reached  by  the  vagina. 

Should  we  regard  dropsy  of  the  uterus,  as  a  dan- 
gerous complaint  ?  It  should  be  so  considered,  but 
chiefly  from  the  morbid  action  going  on  in  the  inner 
surface  of  the  uterus,  and  its  liability  to  ulceration 
through  its  walls  into  the  cavity  of  the  abdomen. 

DISEASES  INCIDENT  TO  PREGNANCY. 

Do  the  sympathetic  or  secondary  disturbances  of 
the  system  during  pregnancy,  sometimes  amount  to 
disease  ?  Yes,  and  are  entitled  to  be  called  the 
diseases  of  pregnancy. 

Into  how  many  classes  may  these  diseases  be 
divided  ?     Into  local  and  general. 

In  what  way  are  the  local  diseases  induced  ?  By 
pressure  and  sympathy. 

What  are  some  of  the  consequences  induced  by  en- 
largement of  the  uterus  ?  Pressure  on  the  neck  of 
the  bladder,  which  prevents  a  free  discharge  of  urine, 
and  often  causes  distension. 

What  consequences  may  result  from  this  distension? 
Retroversion  of  the  uterus,  inflammation  of  the  blad- 
der, &c. 

Does  the  bladder  suff*er  more  or  less  during  the 
later,  than  in  the  earlier  stages  of  pregnancy  ?  Ge- 
nerally it  sufl'ers  less  in  the  later  stages,  because  it  is 
then  flattened  out  over  the  surface  of  the  uterus. 

Can  it  therefore  retain  much  urine  ?  No — but  a 
small  quantity  in  general,  though  it  sometimes  be- 
comes enormously  distended. 


382  PHYSIOLOGY   AND    PATHOLOGY 

What  are  some  of  the  consequences  of  the  pressure 
of  the  developed  uterus  ?  Pain  in  the  right  side, 
similating  liver  complaint. 

Upon  what  depends  the  pain  frequently  felt  in  one 
or  both  of  the  iliac  regions,  as  the  uterus  becomes 
enlarged  ?  Probably  upon  the  stretching  of  the  round 
ligaments. 

Which  of  the  round  ligaments  is  the  shorter  ?  The 
right  one. 

Towards  which  side  of  the  abdomen  does  the  uterus 
usually  incline  as  it  becomes  developed?  Towards 
the  right  side. 

How  is  this  inclination  accounted  for  ?  First,  by 
the  shortness  of  the  right  round  ligament,  and  se- 
condly, by  the  presence  of  the  rectum  on  the  left  side 
of  the  spine  usually. 

•  Does  the  pressure  of  the  fundus  of  the  uterus  up- 
wards, produce  any  inconvenience  to  the  stomach  ? 
It  frequently  causes  dyspeptic  symptoms. 

What  are  some  of  the  effects  of  pressure  upon  the 
bowels  ?  Displacements  through  several  .  natural 
openings  in  some  instances — hence  hernia  in  certain 
periods  of  pregnancy. 

How  are  we  to  account  for  ventral  hernia  in  preg- 
nancy ?  Pressure  of  the  uterus  causes  separation  of 
the  fibres  of  the  abdominal  muscles,  and  the  escape  of 
the  bowel  between  them. 

What  kind  of  displacement  of  the  bladder  is  apt  to 
result  from  pressure  of  the  uterus  upon  it  ?  Hernia 
into  the  vagina,  or  less  frequently  into  the  crural 
ring. 

What  are  some  of  the  effects  of  the  pressure  of  the 
uterus  upon  the  great  blood  vessels  ?  Congestions 
of  the  inferior  vessels,  hemorrhoids,  varicose  veins, 
&c. 

How  is  the  edema,  to  which  some  women  are  sub- 
ject, to  be  accounted  for  ?  By  pressure  of  the  uterus 
upon  the  veins  and  lymphatics. v 

Is  this  pressure  apt  to  affect  the  labia  ?     It  some- 


OF   THE    HUMAN    FEMALE.  ciH'i 

times  causes  great  distension  and  swelling  with  enor- 
mcwis  serous  effusion  in  the  cellular  membrane  of  the 
labia. 

Does  pressure  of  the  uterus  exert  any  unfavorable 
influence  on  the  nerves  of  the  lower  part  of  the 
body  ?  Pressure  on  the  crural  and  obturator  nerves, 
often  causes  cramps,  spasms,  and  neuralgic  pains. 

What  are  the  local  sympathetic  diseases  of  preg- 
nancy ?      Irritation  of  the  uterus  and  adjacent  parts. 

Is  the  excitement  into  which  the  uterus  is  thrown, 
usually  to  be  regarded  as  a  healthy  action  ?  In  the 
natural  state  of  society  it  is  so  ;  but  in  civilized  life, 
this  irritation  often  induces  disease. 

Does  the  vagina  ever  become  sympathetically  af- 
fected ?  It  becomes  the  seat  of  a  sensation  of  full- 
ness, heat,  and  often  a  leucorrhoeal  discharge. 

Does  leucorrhoea  ever  thus  become  a  symptom  of 
pregnancy  ?  In  some  doubtful  cases  this  state  of  the 
vagina  may  aid  in  forming  a  diagnosis. 

Do  the  glands  of  the  vagina  ever  secrete  very  pro- 
fusely during  pregnancy  ?  Sometimes  the  discharge 
is  very  copious,  and  is  occasionally  thrown  out  very 
suddenly. 

From  what  other  parts  at  this  time  may  a  co- 
pious and  sudden  discharge  take  place  ?  Probably 
from  between  the  uterus  and  decidua,  between  the 
decidua  and  chorion,  or  between  the  chorion  and 
amnion. 

What  abnormal  formation  upon  the  ovum  may  give 
rise  to  this  discharge  ?     Hydatids. 

What  peculiarly  distressing  sympathetic  irritation 
is  sometimes  brought  on  in  the  vngina  or  vulva  by 
pregnancy  ?  An  inflammatory  affection,  resembling 
aphthae,  called  pruritis  vulvae. 

What  effect  has  the  pressure  of  the  uterus  ante- 
riorly upon  the  skin  ?  It  sometimes  greatly  distends 
it  and  renders  it  painful. 

Do  the  abdominal  muscles  participate  much  in  the 
consequences  of  this  pressure  ?     They  are  often  put 


384  PHYSIOLOGY   AND    PATHOLOGY 

upon  the  stretclij  and  are  occasionally  thrown  intc 
spasm  and  pain.  ^ 

In  what  pregnancy  are  these  symptoms  the  most 
distressing  ?  Usually,  though  not  always,  in  the 
first. 

What  sympathetic  effect  has  pregnancy  upon  the 
stomach  ?  It  mostly  becomes  disturbed,  the  patient 
being  distressed  with  nausea  and  vomiting. 

Is  the  stomach  always  afflicted  thus  by  pregnancy  ? 
Not  invariably. 

What  kind  of  sensation  is  it  which  women  expe- 
rience at  the  stomach,  or  epigastric  region  ?  A  sense 
of  sinking ;  sometimes  of  fullness,  nausea,  sometimes 
resulting  in  vomiting. 

What  circumstance  aggravates  this  nausea  of  the 
stomach  ?  Motion  ;  it  usually  comes  on  the  moment 
of  rising  from  bed. 

What  is  this  disturbance  usually  called  ?  Morning 
sickness. 

Is  it  confined  to  the  morning  alone  ?  It  sometimes 
lasts  the  whole  day. 

Does  it  always  commence  in  the  morning  ?  It 
sometimes  comes  on  in  the  evening,  the  patient  being 
quite  free  from  it  at  other  times  of  the  day. 

Is  this  morning  sickness  a  popular  sign  of  preg- 
nancy ?  It  is  by  some  persons  regarded  as  an  inva- 
riable or  infallible  sign. 

Do  the  olfactory  and  gustatory  nerves  become  very 
susceptible  with  this  affection  of  the  stomach  ?  Both 
the  smell  and  taste  seem  to  be  affected  with  this  irri- 
tability of  the  stomach. 

Is  the  stomach  affected  by  moral  causes?  It  is 
rendered  worse  by  depressing,  and  better  by  exciting 
moral  causes. 

Does  any  serious  consequence  ever  result  from  this 
irritation  of  the  stomach  ?  Sometimes  it  results  in 
confirmed  dyspepsia. 

What  then  happens  ?  Flatulence,  cardialgia,  py- 
rosis, gastrodynia,  and  salivation. 


OF   THE    HUMAN    FEMALE.  385 

In  what  way  is  the  appetite  depraved  ?  The 
patient  is  apt  to  have  fastidious  tastes,  longings  ; 
desires  for  outre  articles,  as  slate  pencils,  char- 
coal, &c. 

Is  it  necessary  that  this  should  be  indulged? 
Ko — we  should  not  encourage  such  morbid  propen- 
sities. 

What  is  the  popular  notion  respecting  this  ?  That 
these  longings,  if  not  gratified,  will  result  in  some 
defect  or  deformity  of  the  child. 

Is  it  necessary  always  to  withhold  the  object  de- 
sired ?  The  patient  may  be  indulged  in  every  rea- 
sonable desire  without  impropriety. 

Do  these  inconveniences  always  occur  ?  No — 
some  women  are  better  during  pregnancy  than  any 
other  time. 

How  long  do  the  annoyances  alluded  to  generally 
exist  ?  Some  patients  sufier  only  a  month,  some 
three  or  four. 

When  are  they  usually  most  severe  ?  During  the 
second  and  third  months. 

When  does  the  distress  usually  begin  ?  Imme- 
diately after  the  suspension  of  the  menstruation. 

Is  gastritis  ever  a  consequence  of  this  sympathetic 
irritation  ?     Occasionally  this  occurs. 

What  is  the  pathological  condition  of  the  stomach 
in  pregnant  women  ?  Usually  it  is  not  inflamed, 
but  mostly  in  a  state  of  irritation,  or  rather,  accord- 
ing to  some,  of  sedation. 

Is  there  any  indisposition  produced  by  another 
cause,  similar  to  the  sickness  of  pregnancy  ?  Sea 
sickness^  in  which  also  there  is  irritation,  or  sedation 
of  the  nerves  of  the  stomach. 

From  what  may  we  infer  that  the  stomach  is  not 
inflamed  ?  It  is  relieved  by  taking  food,  and  espe- 
cially by  stimuli,  cordials,  &c. 

Is  it  mostly  accompanied  by  any  sympathetic  reac- 
tion ?     There  is  usually  no  sympathetic  fever. 

Is  ordinary  sickness  of  the  stomach  in  pregnancy 


mb  PHYSIOLOGY   AND    PATHOLOGY 

Tisually  productive  of  unpleasant  consequences  ? 
Mostly  without  any  bad  consequences,  however  long 
the  sickness  may  continue. 

What  affords  temporary  relief-?  Lying  down,  fresh 
air,  moral  excitement,  &c. 

Does  the  liver  become  implicated  in  the  consequen- 
ces of  pregnancy  ?  It  often  becomes  the  seat  of  pain, 
and  is  also  sometimes  functionally  deranged. 

What  evidence  have  we  of  hepatic  derangement  ? 
The  urine  is  high  colored,  bowels  are  torpid,  skin 
sallow,  and  sometimes  the  patient  becomes  jaun- 
diced. 

Is  there  any  other  peculiarity  about  the  skin  in 
some  cases  of  pregnancy  ?  It  becomes  covered  by 
brown  or  yellow  spots  called  maculae. 

Where  do  these  spots  usually  appear  ?  Upon  the 
face  and  neck. 

Do  they  present  any  bad  omen  ?  No — they 
are  of  little  consequence,  and  usually  go  off  after 
delivery. 

Upon  what  visceral  derangement  do  they  seem  to 
depend  ?     Upon  the  hepatic  affection. 

What  part  of  the  glandular  system  is  apt  to  sympa- 
thise with  the  gravid  uterus  ?  The  salivary  glands 
sometimes  become  greatly  excited. 

Do  the  gums  become  inflamed  ?     Not  necessarily. 

What  is  the  character  of  the  salivary  discharge  ? 
Thick  and  ropy,  sometimes  very  abundant. 

How  are  the  mammary  glands  affected?  They 
almost  always  become  enlarged,  slightly  painful, 
and  they  occasionally  secrete  milk  very  early  in  preg- 
nancy. 

What  name  is  given  to  a  tumefaction,  which  some- 
times extends  much  beyond  the  ordinary  excitement  ? 
Mastodynia. 

Suppose  the  mammae  after  having  been  distended, 
should  become  shrunken  and  flattened,  what  indica- 
tion would  it  present  ?  That  the  development  of  the 
ovum  had  become  suspended. 


OF   THE    HUMAN   FEMALE.  887 

What  other  sympathies  are  involved  in  pregnancy  ? 
Those  of  a  general  nature  are,  first,  excitements  of 
the  cerebro-spinal  axis ;  and  secondly,  those  of  the 
vascular  system. 

How  are  the  brain  and  the  mental  faculties  affected  ? 
The  brain  becomes  more  impressible,  and  the  mind 
more  susceptible  in  most  cases. 

Does  the  pregnancy  ever  cause  much  depression  of 
the  faculties  ?  The  patient  sometimes  becomes  des- 
pondent, and  thinks  every  thing  is  wrong. 

Does  the  opposite  state  of  things  ever  occur  ?  In 
some  cases  the  sense  of  smell  and  taste  becomes  more 
acute,  and  the  mind  much  more  active  and  effec- 
tive. 

Is  the  vascular  system  necessarily  excited  at  the 
same  time  ?  The  vascular  system  is  not  necessarily 
correspondingly  excited  in  such  cases. 

Is  the  excitement  of  the  cerebrum  ever  attended  by 
mania  ?  In  some  cases,  though  it  rarely  comes  on  till 
after  delivery. 

What  are  some  of  the  consequen*ces  of  this  excite- 
ment of  the  brain  and  spinal  marrow  ?  Hysteric  con- 
vulsions. 

Does  a  moderate  degree  of  this  stimulation  of  the 
nervous  system  ever  produce  a  favorable  result  ?  In 
some  cases  the  patient  is  able  to  use  her  muscles  more 
freely  than  when  unimpregnated. 

What  disturbances  are  produced  in  the  lungs,  or 
thorax  by  this  nervous  excitement?  Dyspnoea;  some- 
times palpitation  and  spasmodic  cough. 

What  effect  has  this  nervous  stimulation  upon  the 
uterus  itself?  It  increases  its  sensibility,  and  ren- 
ders it  often  extremely  sensitive  to  the  touch. 

What  influence  has  it  upon  the  muscular  fibres  of 
the  uterus  ?  It  often  causes  irregular  contractions, 
somewhat  resembling  labor. 

What  effect  has  this  excitation  upon  the  general 
sensibilities  of  the  patient  ?  She  sometimes  has  ner- 
vous chills,  a  kind  of  universal  tremor. 


388  PHYSIOLOGY  and  pathology 

"When  are  these  sensations  experienced  ?  Some- 
times at  the  very  commencement  of  pregnancy. 

Are  they  liable  to  produce  much  muscular  move- 
ment ?  In  some  cases  they  amount  to  regular  hys- 
teria. 

Do  some  patiefits  experience  a  condition  opposite 
to  this  ?     They  become  faint  even  during  sleep. 

Does  this  condition  of  the  uterus  ever  excite  any 
disturbance  of  the  cephalic  nerves  ?  Some  females 
suffer  much  from  otalgia,  odontalgia,  cephalalgia,  &c. 

Is  toothache  very  common  in  pregnancy  ?  With 
some  females  it  is,  and  some  ladies  lose  a  tooth  at 
every  pregnancy,  in  consequence  of  the  recurrence  of 
odontalgia. 

It  has  been  said  that  some  females  become  better, 
more  able  to  make  exertion,  &c.,  during  pregnancy ; 
are  any  patients  in  an  opposite  condition  ?  Some  wo- 
men become  very  feeble,  and  unable  to  walk,  during 
the  greater  part  of  pregnancy,  until  after  delivery. 

PLETHORA. 

We  have  spoken  now  of  the  nervous  excitability  as 
a  consequence  of  pregnancy, — what  are  occasionally 
its  effects  upon  the  vascular  system  ?  Most  young 
women  become  more  developed,  their  vessels  enlarge, 
and  carry  more  blood ;  the  whole  body,  pelvis,  &c.,  be- 
come increased  in  size. 

Is  this  a  natural  and  salutary  consequence  of  preg- 
nancy ?     It  should  be  so  regarded. 

How  is  this  change  brought  about?  By  a  pletho- 
ric condition  of  the  blood  vessels. 

Under  what  circumstances  does  this  plethora  become 
an  evil  ?  In  civilized  life,  females  who  live  luxuriantly, 
and  do  not  use  much  physical  exertion  become  subject 
to  local  congestions. 

What  then,  is  the  best  remedy  for  the  natural  ple- 
thora of  pregnancy  ?  Free  exercise  and  temperate 
living. 

What  sympathetic  disturbance  is  a  usual  preventive 


OF   THE   HUMAN    FEMALE.  389 

of  plethora  ?  Nausea  and  vomiting,  as  in  the  morn- 
ing sickness. 

After  what  period  of  pregnancy  does  plethora  usually 
exist  most  conspicuously  ?  The  fourth  month,  and 
later  when  the  stomach  usually  has  become  more 
tranquil. 

What  kind  of  pulse  is  presented  in  this  plethora  ? 
It  is  not  frequent ;  rather  slow  and  full,  indicating 
congestion. 

What  is  the  condition  of  the  veins  ?  They  are  com- 
monly very  full. 

What  are  some  of  the  consequences  of  this  plethora  ? 
Sense  of  general  fullness — headache,  particularly  on 
lying  down. 

How  is  the  respiration  aifected  ?  It  is  oppressed, 
and  there  is  usually  a  difficulty  in  taking  a  deep  inspi- 
ration. 

What  is  the  condition  of  the  heart,  in  this  general 
plethora  ?  It  labors  irregularly  and  with  difficulty ; 
there  is  palpitation  combined  with  oppression. 

CONSEQUENCES  OF  EXCESSIVE  PLETHORA. 

What  is  the  consequence  of  the  congestion  of  the 
portal  system  ?  Distress  in  the  epigastric  region,  and 
aggravation  of  the  dyspeptic  symptoms  where  they 
co-exist. 

What  effect  has  plethora  upon  the  viscera  at  the 
lower  part  of  the  abdomen  ?  Sensation  of  weight 
and  distress,  especially  at  the  usual  menstrual  pe- 
riod. 

What  evil  consequences  may  arise  from  plethora  in 
the  uterus?  Hemorrhage  from  the  cervix,  or  from 
the  inner  surface  of  the  uterus,  from  detachment  of 
the  placenta. 

Is  it  of  importance  to  attend  to  these  symptoms  ? 
They  sometimes  become  exceedingly  dangerous  and 
should  be  carefully  watched. 

Does  this  plethora  ever  cause  effusions  of  blood  in 
any  other  part  than  the  uterus  ?  Hsemoptisis,  ha^mc- 
33* 


390  PHYSIOLOGY   AND   PATHOLOGY 

tamesis,  sanguineous  apoplexy  of  brain  or  lungs,  and 
melanosis,  may  result  from  it. 

What  other  evil  may  happen  from  extreme  turges- 
cence  of  the  blood  vessels  in  the  brain  ?    Convulsions. 

What  other  species  of  efiusion  may  result  from  this 
plethoric  condition  of  the  vascular  system  ?  Serous 
effusions  upon  the  brain,  into  the  thorax,  the  abdo- 
domen  and  the  general  cellular  tissue,  &c. 

What  effect  have  these  effusions  upon  the  excited 
condition  of  the  nervous  system  ?  They  aggravate 
the  irritability  of  the  nervous  system. 

How  are  the  bowels  sometimes  affected  by  it?  They 
sometimes  pour  off  the  water  or  serum  of  the  blood  in 
large  amounts. 

What  is  the  general  condition  of  the  blood,  in  a 
pregnant  female  ?  It  is  usually  altered  ;  has  more 
coagulable  lymph  or  buff  upon  it  when  drawn. 

Is  this  the  result  of  inflammatory  action,  during 
pregnancy  ?  It  is  not  necessarily  dependent  upon  in- 
flammatory action. 

Is  this  plethoric  condition  never  attended  by  fever  ? 
In  some  cases,  it  is  combined  with  fever  and  inflam- 
matory action. 

FEVER  FROM  NERVOUS  IRRITATION. 

How  should  we  regard  a  little  febrile  condition  of 
the  patient  if  she  have  no  plethora  ?  It  is  not  to  be 
looked  upon  as  a  serious  affair.  It  is  usually  remedied 
by  cooling  medicines,  and  generally  goes  off  after  de- 
livery. 

What  is  it  apparently  the  result  of?  Nervous 
excitability;  it  is  not  apt  to  be  followed  by  debihty. 

What  are  the  symptoms  of  this  nervous  fever? 
Dry  skin,  small  pulse,  &c. 

BEST  REMEDY  FOR  IT. 

What  means  are  best  calculated  to  relieve  this  irri- 
tability of  pregnancy  ?  Cold  bath,  sponging  with  cold 
water. 


OP   THE   HUMAN   FEMALE.  391 

What  might  we  regard  as  suitable  temporary  reme- 
dies ?  Mild  anodynes;  particularly  those  of  an  anti- 
spasmodic character,  as  assafoetida,  ether,  &c. 

Why  not  use  the  narcotic  anodynes,  as  camphor, 
and  opium,  &c.  ?  When  the  system  becomes  habi- 
tuated to  the  use  of  them,  the  irritability  is  usually 
increased  ? 

Is  it  safe  to  deplete  very  much,  during  pregnancy  ? 
Too  much  depletion  induces  debility,  and  conse- 
quently increases  irritation. 

MILD  TREATMENT  MOST  PROPER  IN  PREGNANCY. 

Should  the  treatment  of  pregnant  women  generally 
be  mild  or  active  ?  The  treatment  should  be  mild  in 
most  cases. 

Should  it  be  preventive  or  hygienic,  rather  than 
corrective  or  medical  ?  It  should  be  rather  prophy- 
lactic and  hygienic — the  professional  counsellor  should 
give  proper  attention  to  suitable  exercise  of  body  and 
mind,  rather  than  medicine  in  most  cases. 

What  general  rules  should  be  laid  down.  In  refer- 
ence to  diet  ?  It  should  be  light,  easy  of  digestion ; 
chiefly  vegetable. 

Suppose  the  patient  is  dyspeptic,  and  subject  to  fla- 
tulence ?  Allow  her  some  light  animal  food,  and  mild 
condiments. 

What  rule  should  be  observed  in  regard  to  her 
drinks?  They  should  be  simple,  and  in  moderate 
quantities. 

What  ill  consequences  may  arise  from  drinking 
large  quantities  even  of  water  ?  In  the  opinion  of 
some,  it  is  apt  to  increase  plethora. 

What  popular  prejudice  exists  in  regard  to  the 
amount  of  diet,  required  by  pregnant  women  ?  That 
they  require  more  food  while  pregnant,  and  that  it 
should  be  richer  and  better  than  usual. 

How  far  should  this  idea  be  favored  ?  Though  it  is  in 
general,  fair  to  suppose  that  a  woman  in  this  situation 


892  PHYSIOLOGY   AND    PATHOLOGY 

would  require  more,  yet  due  prudence  is  requisite  in 
the  indulgence  of  a  very  strong  appetite. 

After  the  period  of  morning  sickness  has  passed, 
what  should  she  do  to  remove  plethora  ?  She  should 
use  as  much  exercise  as  may  be  consistent  with  her 
physical  ability. 

EXERCISE  DURINa  PREGNANCY. 

What  are  some  of  the  good  effects  of  exercise  ? 
When  taken  regularly  and  in  moderation,  it  excites 
secretion,  and  prevents  dyspepsia,  increases  strength 
and  removes  irritability. 

Suppose  the  patient  be  too  feeble  to  walk,  what 
kind  of  exercise  can  she  substitute  for  it  ?  Riding, 
sailing,  &c. 

What  are  some  of  the  disadvantages  of  too  much 
exercise  ?  Pain,  fatigue,  spasms,  abortion  or  prema- 
ture labor. 

Suppose  your  patient  was  already  very  plethoric, 
would  you  oblige  her  to  use  exertion  to  wear  it  off? 
This  plethora  should  first  be  reduced  by  proper 
direct  means  before  she  be  recommended  to  use 
exertion. 

What  treatment  of  a  general  nature,  is  proper 
to  allay  the  great  irritability  of  some  pregnant 
women  ?  General  bathing,  using  merely  the  cold 
bath. 

Suppose  the  cold  bath  is  followed  by  a  sense  of 
chilliness,  what  should  be  substituted  ?  It  should  be 
tepid,  or  warm,  followed  by  moderate  friction  upon 
the  skin. 

What  peculiar  advantages  does  the  warm  bath 
offer  at  the  later  stages  of  pregnancy  ?  It  is  very 
useful  to  promote  the  relaxation  of  the  system. 

What  consequences  might  occur  if  the  bath  were 
too  hot  ?  Labor  might  be  brought  on,  especially  if 
the  woman  be  plethoric. 

VENESECTION,   &c. 

What  are  some  of   the  more   distinct   means  of 


OF   THE   HUMAN   FEMALE.  393 

reducing  plethora  ?  Venesection  is  the  most  effi- 
cient. 

How  do  pregnant  women  usually  bear  bleeding  ? 
Very  well — most  of  them  think  they  require  it,  and 
to  many  of  them  it  is  almost  indispensable. 

Is  it  better  to  bleed  freely  and  rarely,  if  you  bleed 
at  all,  than  to  bleed  a  little,  and  often  ?  Bleed  freely, 
and  empty  the  turgid  vessels. 

After  a  free  bleeding,  whereby  a  plethoric  state  is 
removed,  what  are  the  best  measures  for  preventing 
its  return  ?  Free  exercise,  bathing,  aperient  medi- 
cines, mild  diaphoretics,  &c. 

How  would  you  treat  a  local  inflammation,  as  pleu- 
ritis,  hepatitis,  &c.,  during  pregnancy  ?  By  free 
bleeding,  and  after  the  reduction  of  the  inflammation, 
an  early  use  of  opiates. 

Why  resort  to  opiates?  To  prevent  the  strong 
liability  to  premature  uterine  contractions. 

What  unfavorable  influence  may  irritation  of  the 
bowels  exert  upon  the  uterus  ?  It  is  very  likely  to 
bring  on  contractions,  and  false  pains. 

What  treatment  is  proper  in  the  febrile  state  of  the 
system  accompanied  by  nervous  chills,  and  debility  ? 
Here  omit  venesection,  but  administer  instead,  spirits 
of  nitre,  and  mild  diaphoretics. 

What  should  be  done  during  the  apyrexia  ?  Mild 
tonics  should  be  given. 

What  advice  should  be  given  the  patient,  when  she 
experiences  difiiculty  in  urinating  in  consequence  of 
the  pressure  of  the  uterus  ?  To  bear  forward,  or  to 
place  herself  on  her  knees,  and  if  necessary,  press  the 
uterus  upward,  when  it  rests  upon  the  pubes. 

Suppose  this  means  will  not  aff"ord  her  the  neces- 
sary relief,  what  should  be  done  ?  Introduce  the 
catheter,  and  allow  the  urine  to  escape  through  it. 

CATHETERISM. 
What  precautions  are  to  be  taken,  in  the  introduc- 
tion of  the  instrument   under   such   circumstances  ? 


394  PHYSIOLOGY   AND    PATHOLOGY 

Bear  in  mmd,  that  as  the  bladder  is  compressed  by 
the  uterine  tumor,  it  is  usually  carried  so  high  up  as 
to  put  the  urethra  upon  the  stretch,  and  fix  it  parallel 
with  the  posterior  surface  of  the  symphysis  pubes, 
and  that  the  bladder  itself  is  pressed  forward  over  the 
symphysis.  Consequently,  the  point  of  the  catheter, 
is  to  be  carried  along  parallel  with  the  symphysis 
until  it  gets  above  it ;  the  handle  is  then  to  be  de- 
pressed, in  order  to  carry  the  point  of  the  instrument 
into  the  cavity  of  the  bladder. 

What  evil  consequences  may  result  from  the  long 
retention  of  the  urine  ?  Paralysis  of  the  bladder,  or 
its  rupture  and  the  death  of  the  patient. 

What  useful  mechanical  measure  may  be  resorted 
to,  to  obviate  or  remove  the  pressure  of  the  uterus 
upon  the  bladder  ?  A  broad  bandage  applied  in  front 
of  the  lower  part  of  the  abdomen  and  carried  round  to 
the  back,  or  even  across  the  shoulders. 

When  the  uterus  presses  upon  the  rectum,  and 
causes  a  tenesmus,  how  should  it  be  relieved  ?  By 
pressing  the  uterus  upward. 

APERIENTS,    &c. 

What  means  should  be  used  to  remove  the  im- 
pacted feces  from  the  rectum  ?  If  oleaginous  in- 
jections do  not  succeed,  the  mass  must  be  removed 
by  a  finger  or  a  spoon-handle,  or  some  similar  in- 
strument. 

How  is  the  pain  which  is  often  felt  in  the  abdo- 
minal muscles,  the  skin,  &c.,  to  be  relieved  ?  By 
rubbing  them  with  oleaginous  and  anodyne  mixtures. 

Supposing  much  of  the  abdominal  pain  to  depend 
upon  the  existence  of  flatus  in  the  intestines,  what 
should  be  done  to  relieve  it  ?  Remove  the  flatus  by 
some  carminative  or  gently  stimulating  laxative,  or 
antispasmodic. 

If  the  intestines  become  inflamed,  how  may  they  be 
treated  ?     By  cups,  leeches,  &c.,  to  the  sides  of  the 


OF   THE    HUMAN   FEMALE.  395 

abdomen  ;  and  the  other  modes  of  treatment  consi- 
dered proper  in  ordinary  cases. 

What  other  cause  may  give  rise  to  pain  in  some 
portion  of  the  abdomen  ?  Either  of  the  varieties  of 
hernia,  if  they  become  strangulated,  or  the  bowel 
inflamed. 

HOW  TO  TREAT  HERNIA. 

What  is  the  proper  mode  of  treating  hernia  ?  Ee- 
duce  it  and  keep  it  supported  by  a  proper  truss  or 
bandage,  which  presses  upon  the  opening  only — pro- 
perly adjusted  adhesive  straps  often  answer  this 
purpose  very  well. 

What  is  the  most  usual  kind  of  vesical  hernia? 
Into  the  vagina,  although  it  has  been  known  to  take 
place  into  the  abdominal  or  the  crural  ring. 

How  is  it  to  be  relieved  ?  By  supporting  the  su- 
perincumbent uterus  by  a  proper  bandage. 

CAUTION  ABOUT  DRESS,    &c. 

What  caution  should  pregnant  women  observe  in 
regard  to  dress  ?  It  should  be  such  as  to  make  no 
pressure  on  the  abdomen ;  they  should  abandon  the 
use  of  corsets,  or  have  them  so  constructed  as  not  to 
compress  the  body. 

How  should  the  hemorrhoids  of  pregnant  women  be 
treated  ?  By  laxatives,  leeches,  cold  poultices,  &c. 
They  should  be  speedily  returned  within  the  sphinc- 
ter, whenever  they  become  prolapsed. 

What  is  the  proper  treatment  for  varices  ?  Bleed- 
ing and  skilful  bandaging. 

Can  all  patients  who  are  troubled  with  varices  bear 
to  have  their  limbs  firmly  bandaged  ?  In  some  cases 
bandages  which  compress  the  limbs  cause  a  sense  of 
extreme  suffocation. 

What  other  exciting  cause  besides  pressure  is  liable 
to  produce  anasarca,  varices,  &c.,  in  pregnant  women? 
General  plethora. 

What  serious  evil  may  be  apprehended  from  great 


396  PHYSIOLOGY   AND    PATHOLOGY 

distension    of    the   lower   extremities   by   anasarca? 
Gangrene  and  sloughing. 

What  surgical  treatment  does  it  sometimes  require  ? 
Evacuation  by  puncturing. 

TREATMENT  OF  SYMPATHETIC  VAGINITIS  AND  PRU- 
RITIS  VULV^,  IRRITATION  OF  THE  BLADDER,  DIAR- 
RHCEA,  &c. 

How  is  the  sympathic  vaginitis  of  pregnant  women 
to  be  treated  ?  When  the  patient  is  plethoric,  by 
free  general  bleeding,  then  followed,  if  necessary,  by 
leeching  and  cold  astringent  washes,  and  alterative 
injections  of  nitrate  of  silver,  of  alum,  &c.^ 

PRURITIS  VULViE. 

What  means  should  be  resorted  to  for  the  relief  of 
pruritis  vulvae  ?  General  bleeding,  if  plethoric,  and 
then  mucilaginous  injections,  well  charged  with  bo- 
rax, and  occasionally  with  laudanum,  or  better  still, 
the  aqueous  solutions  of  opium. 

Under  what  circumstances  would  the  sulphate 
of  zinc  or  nitrate  of  silver  be  useful  ?  After  the 
removal  of  the  plethora. 

How  strong  a  solution  of  the  nitrate  of  silver  should 
be  used  ?  Two,  three,  or  four  grains  to  the  ounce  of 
water. 

IRRITATION  OF  THE  BLADDER,  BOWELS,  STOMACH,  &c. 

How  should  we  treat  irritation  of  the  bladder  ?  By 
the  use  of  bland  diuretics. 

What  treatment  is  most  proper  for  the  diarrhoea 
of  pregnant  women  ?  As  it  is  mostly  the  result  of, 
or  accompanied  by,  inflammatory  action,  it  should 
be  treated  by  depletion,  mild  laxatives,  regulated 
diet,  &c. 

When  might  astringents  be  used  ?  After  the  in- 
flammation has  been  cured. 

Should  the  remedies  applied  to  the  stomach  for 
morning  sickness  be  curative  or  palliative  only  ?      Pal- 


OF  THE   HUMAN   FEMALE.  397 

liatlve  only — thus,  let  the  patient  eat  before  she  rises  ; 
let  her  take  her  cup  of  coffee  and  a  piece  of  bread 
in  bed,  or  instantly  after  rising.  Her  food  should 
be  solid  mostly;  she  should  not  indulge  much  in 
liquids. 

What  should  she  do  if  she  becomes  again  sick  after 
eating  ?  Lie  down  at  once,  or  go  directly  out  and 
walk  in  the  open  air. 

What  temporary  medicines  may  she  take  to  relieve 
the  vomiting,  when  it  is  urgent  ?  Lime  water  and 
milk,  and  other  antacids.  Hot  drinks,  as  catnip  tea, 
infusions  of  cloves,  nutmegs,  mace,  &c. 

Suppose  more  active  measures  be  necessary,  what 
other  articles  may  be  administered  ?  Spirits  of  tur- 
pentine in  small  doses,  and  wine  in  moderate  quanti- 
ties :  the  aromatic  sulphuric  acid  may  be  adminis- 
tered, and  in  some  urgent  cases,  sinapisms  may  be 
applied  over  the  region  of  the  stomach. 

What  notice  should  we  take  of  her  longings,  if  her 
sickness  be  urgent  ?  They  should  be  gratified  to 
avoid  irritability,  unless  she  desires  improper  and 
outr^  articles. 

What  organ  should  we  regard  as  the  primary  seat 
of  irritation  of  the  stomach  ?  The  uterus ;  and 
hence  none  other  than  mild  palliative  measures  can 
^  e  useful. 

If  the  liver  become  torpid  and  jaundice  occur,  how 
rust  it  be  treated  ?  By  mild  alteratives,  a  gentle 
mercurial  course,  and  especially  the  proper  use  of 
alkalies. 

Suppose  the  secretions  from  any  organ  become  very 
a'^  indant  during  pregnancy,  how  should  they  be  man- 
a^od  ?  Great  care  should  be  taken  not  to  arrest  them 
suddenly. 

Suppose  the  patient  suffered  from  mastodynia  ? 
Care  should  be  taken  not  to  remove  it  at  once  by  the 
application  of  cold,  for  fear  of  causing  a  metastasis. 
It  should  be  moderated  by  warm  application,  leeches, 
&c.,  if  necessary. 

34 


398  PHYSIOLOGY   AND    PATHOLOGY 

What  kind  of  plaster  is  very  useful,  and  usually 
sufficient  to  relieve  it  ?  The  Diachylon  or  soap 
plaster. 

What  other  means  often  succeed  ?  Frictions  with 
anodyne  liniments. 

Is  it  important  to  distinguish  neuralgia  of  a  part 
from  inflammation  ?  It  is  :  and  the  treatment  should 
be  conducted  accordingly. 

What  kind  of  anodynes  are  best,  if  the  pain  be 
purely  nervous  ?  Camphor,  hyosciamus,  ether,  assa- 
foetida,  &c.,  but  not  opium. 

How  should  we  treat  the  pains  in  the  chest  in 
pregnant  women  ?  With  cups,  leeches,  &c.,  if  in- 
iiammation  exist ;  but  if  it  be  merely  neuralgic,  pal- 
liate with  assafoetida,  camphor,  &c.,  carefully  with- 
holding opium,  if  possible. 

Suppose  there  is  pain  in  the  abdomen,  with  indica- 
tions for  bleeding,  what  subsequent  treatment  should 
be  used  ?  In  such  cases,  after  proper  sanguineous 
depletion,  give  opiates  by  the  stomach,  or  in  enemata, 
to  prevent  the  contractions  of  the  uterus. 

How  should  we  treat  a  severe  cephalalgia  or 
otalgia  ?  By  leeches,  laxatives,  &c.,  upon  general 
principles,  and  after  excitement  is  allayed,  give  ano- 
dynes. 

Suppose  the  woman  have  severe  tooth  ache,  what 
objection  would  there  be  to  the  extraction  of  the 
tooth  ?  Any  sudden  and  powerful  shock,  as  that  of 
extraction  of  teeth,  might  bring  on  contractions  of 
the  uterus,  and  result  in  premature  delivery.  It  is 
therefore  better,  as  soon  as  it  is  admissible,  to  give 
anodynes. 

CARE  TO  BE  TAKEN  OF  THE  MAMM^. 

What  care  should  be  taken  of  the  mammae  of  preg- 
nant females  ?  The  condition  of  the  mammary 
glands  should  be  enquired  into  in  the  latter  periods 
of  gestation,  and  especial  regard  should  be  had  to  the 
state  of  the  nipple. 


OF   THE   HUMAN   FEMALE.  390 

What  are  some  of  the  conditions  to  which  the  nip- 
ples are  subject  ?  In  many  females,  primips  espe- 
cially, the  central  portions  of  the  nipples  are  so  um- 
bilicated  as  to  be  scarcely  visible  :  in  some  there  is  a 
sulcus  running  across  the  disc  of  the  efferent  ex- 
tremities of  the  gland,  so  that  the  two  halves  of  it  are 
introverted. 

What  consequences  are  likely  to  arise  from  this 
condition  ?  First :  The  conversion  of  the  true  skin 
which  should  cover  and  protect  the  end  of  the  nip- 
ples, into  a  thin  epithelial  secreting  surface  on 
which  the  nervous  papilloe  are  much  exposed,  and 
which  evince  an  exalted  sensibility  whenever  touched, 
and  especially  when  subjected  to  the  suction  by  the 
child. 

What  treatment  should  be  adopted  to  correct  this 
condition,  if  possible,  before  the  breast  is  brought 
into  use  ?  By  some  judicious  means,  as  by  the  gen- 
tle application  of  a  breast  pipe,  to  be  exhausted  by 
the  mouth  of  the  patient,  or  by  a  gum  elastic  bag  or 
air-pump,  till  the  nipple  becomes  elongated  and  the 
efferent  ducts  are  brought  into  parallel  lines. 

Does  this  plan  succeed  effectually  in  a  short  time  ? 
In  the  majority  of  cases  it  requires  great  perse- 
verance, inasmuch  as  in  most,  the  nipple  has  to  ac- 
quire a  development  in  the  right  direction  before  its 
permanency  can  be  relied  upon. 

What  may  be  said  of  astringent  or  moderately 
stimulating  washes  in  those  cases  ?  Judiciously  ap- 
plied, in  moderately  active  potions,  they  will  often 
contribute  to  the  hardening  of  the  investment  of  the 
lactiferous  ducts,  and  prepare  them  for  the  use  of  the 
child  after  its  birth. 

Is  there  any  other  condition  to  which  the  nipple 
of  the  primiparous  or  multiparous  female  is  subject, 
that  is  unfavorable  to  comfort  of  the  mother  or  child 
when  needed  for  nursing  ?  The  nipple  is  sometimes 
chapped,  fissured  or  sulcated  more  or  less  deeply,  the 
substance  between  the  different  sulci  resembling  tho 


400  PHYSIOLOGY    AND    PATHOLOGY 

granules  of  a  ripe  blackberry,  and  in  some  instanceg 
broken  out  nearly  as  easily.  The  sulci  are  mostly 
the  seat  of  an  exalted  sensibility  whenever  the  nipple 
suiFers  from  the  least  irritation. 

HEMORRHAGES  FROM  THE  UTERUS  DURING  PREGNANCY. 

How  are  hemorrhages  from  the  uterus  during  preg- 
nancy classified  ?  Into  avoidable  or  accidental  and 
unavoidable. 

What  is  meant  by  accidental  or  avoidable  hemor- 
rhage ?  That  which  occurs  at  any  period  of  preg- 
nancy from  an  accidental  detachment  of  the  placenta 
when  it  is  situated  at  a  portion  of  the  uterus,  the 
development  of  which  is  proportionate  to  that  of  the 
placenta  itself,  as  about  the  bod}^  or  fundus  of  the 
organ. 

UNAVOIDABLE  HEMORRHAGE— PLACENTA-PR^VIA. 

What  do  you  mean  by  unavoidable  hemorrhage  ? 
It  is  that  which  inevitably  occurs  from  the  detachment 
of  some  portion  of,  or  the  entire  placenta  from  the 
uterus,  in  consequence  of  its  being  situated  at  a  part 
which  is  developed  more  rapidly  than  the  placenta 
itself. 

Is  the  hemorrhage  necessarily  constant  in  this 
case  ?  It  may  be  arrested  temporarily  by  the  pro- 
cess of  coagulation,  but  it  is  subject  to  constant  re- 
currence. 

What  are  the  means  of  diagnosis  in  these  cases  ? 
Examination  per  vaginam,  by  which  you  can  feel  the 
fibrous  structure  of  the  placenta  over  the  os  uteri. 

How  much  of  the  hand  should  be  introduced  into 
the  vagina  for  this  purpose  ?  In  order  fully  to  appre- 
ciate the  existence  of  placenta  prsevia,  it  is  mostly 
necessary  to  pass  in  the  entire  hand. 

HOW   MANAGED. 
How  are  you  to  proceed  to  arrest  the  hemorrhage  in 
this  case  ?     It  has  been  prooosed  to  place  the  patient 


OF   THE   HUMAN   FEMALE.  401 

in  a  recumbent  posture  with  her  hips  elevated,  keep  her 
circulation  as  much  reduced  as  may  be  consistent  with 
her  health,  and  then  resort  to  such  medical  means  as 
favor  coagulation  of  the  blood. 

Are  you  ever  to  resort  to  version  for  the  purpose 
of  eiFecting  delivery  before  term  ?  This  has  been  pro- 
posed, and  directions  given  to  force  open  the  os  uteri 
for  this  purpose,  but  we  regard  it  as  highly  improper. 
We  think  a  better  method  would  be  (if  any  be  called 
for,)  to  perforate  the  placenta,  allow  the  liquor  amnii 
to  escape  and  the  uterus  to  contract  upon  the  fetus, 
&c.,  as  in  cases  of  premature  artificial  delivery,  when 
the  pelvis  is  known  to  be  too  small  for  delivery  at 
term. 

What  means  have  you  of  arresting  the  hemorrhage 
mechanically  ?  The  tampon,  which  may  be  cautiously 
applied,  and  continued  until  complete  dilation  occurs, 
and  the  uterus  expels  it,  the  coagula,  the  placenta  and 
the  fetus  from  its  cavity. 

Should  you  keep  down  the  force  of  the  circulation, 
favor  the  coagulation  of  blood,  by  absolute  rest,  by 
the  use  of  tampon,  &c.,  even  though  you  have  to 
continue  this  plan  for  some  months  ?  We  think  this 
would  be  the  appropriate  plan  of  treatment. 

Suppose  you  find  hemorrlnwge  coming  on  at  the  full 
period  of  gestation,  should  you  palliate  during  the 
first  stage  of  labour  ?  Yes ;  never  introduce  the 
hand  till  the  os  uteri  is  dilated  or  dilatable. 

How  are  you  to  proceed,  as  soon  as  the  second 
stage  of  labor  commences  ?  Pass  up  a  hand,  punc- 
ture the  ovum,  facilitate  as  fast  as  possible  the  de- 
livery of  the  child,  and  as  soon  as  it  is  born,  place 
the  other  hand  on  the  fundus  of  the  uterus,  and  ensure 
its  complete  contraction. 

May  not  the  pressure  of  the  head  or  breech  or 
body  of  the  child  in  the  os  uteri,  arrest  for  a  time  the 
hemorrhage  ?     It  will  sometimes  do  so. 

Suppose  the  pains  are  slow,  and  the  head  is  above 
the   superior   strait?       Turn   and  deliver,    or  give 
34* 


402  PHYSIOLOGY   AND   PATHOLOGY 

ergot,  and  as  soon  as  the  head  is  within  reach,  apply 
the  forceps.  Treat  the  third  stage  according  to 
established  usage. 

In  cases  of  placenta  praevia,  as  soon  as  the  os  uteri 
is  dilated,  what  are  you  to  do  ?  Pass  your  fingers, 
and  then  whole  hand,  between  the  placenta  and  sur- 
face of  the  uterus,  seize  the  breech,  knees,  feet,  and 
deliver  footling. 

What  other  practice  has  been  proposed  by  some  of 
the  German  physicians  in  such  cases  ?  To  let  the 
child  alone,  fill  the  vagina  with  a  tampon,  made  of 
strips  of  bandage,  portions  of  which  can  be  removed 
as  the  head  or  presenting  part  is  protruded  through 
the  uterus ;  and  when  it  is  fairly  within  reach,  use 
forceps,  blunt  hook,  or  other  authorized  means  for 
expediting  the  delivery. 

RETROVERSION  OF  THE  UTERUS  IN  PREGNANCY. 

What  do  you  mean  by  retroversion  of  the  uterus  ? 
That  in  which  the  fundus  of  the  uterus  is  thrown 
down  into  the  hollow  of  the  sacrum,  while  the  os  tincse 
is  carried  up  behind  the  pubes. 

Is  pregnancy  ever  complicated  by  this  accident  to 
the  uterus  ?  Numerous  instances  have  occurred  of 
this  variety  of  displaceiHent  of  the  uterus  after  it  had 
begun  to  gestate  with  a  matured  and  fecundated 
ovum. 

During  what  period  of  gestation  may  this  condition 
of  the  uterus  take  place  ?  During  the  first  three 
months  only,  since  after  this  period  it  is  too  late  to 
change  its  position  in  this  direction. 

At  what  time  are  you  to  expect  that  labor  will 
take  place  in  this  case  ?  Generally  before  the  sixth 
month. 

Have  any  women  laboring  under  this  accident  ever 
reached  the  full  term  of  gestation  ?  Very  few,  if  any 
instances  are  recorded,  except  perhaps  some  which 
have  been  mentioned  by  Dr.  Merriman,  an  English 
accoucheur  and  author. 


OF   THE   HUMAN    FEMALE.  403 

What  are  the  inconveniences  and  dangers  arising 
from  this  accident  ?  Retention  of  urine  and  feces 
from  pressure ;  more  or  less  paralysis  also  of  the 
lower  extremities ;  inflammation  and  sloughing  of  the 
bladder,  rectum,  and  uterus. 

How  may  retroversion  of  the  gravid  uterus  hazard 
the  life  both  of  mother  and  fetus  ?  By  the  fatal 
pressure  which  the  developing  organ  may  exert  upon 
the  bladder  in  front  and  the  rectum  behind,  causing 
inflammation  and  sloughing  of  either  or  both,  but 
particularly  the  former  viscus.  The  embryo  or  fetus 
may  also  have  its  vitality  destroyed  by  the  resistance 
off'ered  to  its  circulation  and  development  in  conse- 
quence of  the  close  confinement  of  the  uterus  in  the 
cavity  of  the  pelvis. 

What  are  the  usual  causes  of  retroversion  ?  Vio- 
lent straining,  as  in  jumping,  falling,  &c.  Efl'orts  at 
defecation  while  constipated ;  too  great  a  distension 
of  the  bladder ;  the  superincumbent  pressure  of  im- 
pacted feces  in  the  colon,  &c. 

What  are  the  symptoms  of  retroversion  of  the 
uterus?  Constant  bearing  down  sensation,  great  dif- 
ficulty, or  utter  impracticability  of  evacuating  the 
bowels  or  bladder,  &c. 

What  is  the  most  prominent  symptom,  and  also  the 
most  dangerous  one  ?  Retention  of  urine,  and  dis- 
tension to  the  immediate  danger  of  rupture  of  the 
bladder  is  the  earliest  urgent  symptom,  though  when 
in  some  cases  the  urine  can  be  evacuated  artificially, 
and  the  bowels  accommodate  themselves  to  the  aid  of 
art,  the  condition  of  developing  uterus  and  ovum  be- 
comes the  subject  of  great  concern. 

As  many  of  these  rational  signs  are  fallacious, 
how  are  we  to  determine  the  existence  of  the  re- 
troversion of  the  uterus  ?  By  the  introduction 
of  the  finger  into  the  vagina,  and  discovering  that 
the  OS  tincye  is  closely  forced  up  behind  the  pubes, 
while  the  body  is  thrown  backwards  into  the  hollow 


404  PHYSIOLOGY  AND    PATHOLOGY 

of  the  sacrum,  and  the  vagina  thereby  very  much 
shortened. 

What  are  the  indications  for  treatment  ?  Reduc- 
tion or  restoration,  if  possible  ;  but  if  the  uterus  be 
so  far  developed  as  not  to  admit  of  being  replaced, 
we  must  palliate  by  artificially  evacuating  the  blad- 
der and  bowels  ;  if  the  enlargement  of  the  uterus 
produce  serious  inconvenience,  it  will  be  necessary  to 
induce  abortion,  by  rupturing  the  membranes  if 
possible,  by  a  stilet  passed  into  the  os  tincse ;  but  if  not, 
by  a  puncture  through  the  substance  of  the  uterus, 
either  directly  through  the  vagina,  or  through  the 
recto-vaginal  septum. 

ANTEVERSION  AND  HERNIA  OF  THE  UTERUS  IN  PREG- 
NANCY. 

What  other  displacements  of  the  uterus  may  com- 
plicate pregnancy  ?  Anteversion  of  the  uterus,  and 
hernia  of  the  uterus. 

What  consequences  to  pregnancy  may  happen  from 
either  of  these  conditions  ?  Little  inconvenience  can 
happen  to  pregnancy  from  anteversion  of  the  uterus, 
as  it  is  usually  rectified  in  proportion  as  it  becomes 
developed ;  but  with  regard  to  hernia  of  the  organ, 
this  sort  of  displacement  would  entail  serious  conse- 
quences upon  gravidity. 

ABORTION  AND  PREMATURE  DELIVERY. 

What  is  to  be  understood  by  the  term  abortion  in 
obstetric  language  ?  It  signifies  the  separation  of  an 
ovum  from  the  mother's  organs  previous  to  the  com- 
pletion of  its  development. 

To  within  what  period  of  gestation  do  we  limit 
the  term  abortion  ?  Till  the  end  of  the  sixth 
month. 

What  do  we  call  the  expulsion  of  an  ovum  at 
any  time  between  the  end  of  the  sixth,  and  the  end 
of  the  ninth  month  of  gestation  ?     Premature  delivery. 

How   many   varieties    or   modes    of    abortion   are 


OF   THE   HUMAN   FEMALE.  405 

there  ?  Two :  one  in  which  the  ovum  is  detached 
merely,  and  the  other,  in  which  it  is  not  only  de- 
tached, but  expelled. 

Upon  w^hat  conditions  may  abortion  depend  ? 
First :  Those  peculiar  to  the  mother.  Second  :  Those 
peculiar  to  the  child. 

What  are  the  various  causes  of  abortion  ?  Some 
depend  upon  the  state  of  the  system  generally,  some 
upon  the  state  of  the  uterus  itself. 

What  condition  of  the  general  system  of  the  mother 
favors  abortion  ?  Any  extremes  of  health,  as  plethora, 
asthenia,  great  irritability  of  the  nervous  system,  &c. 
Syphilis,  and  other  severe  constitutional  irritation, 
accidental  diarrhoea,  active  catharsis  caused  by  drastic 
purgatives,  &c. 

What  condition  of  the  uterus  is  favorable  to,  or  pre- 
disposes to  this  accident  ?  Plethora  ;  the  menstrual 
nisus  ;  irritability  of  its  fibre,  &c. 

Does  the  female  necessarily  abort  when  subjected 
to  the  influence  of  these  predisposing  causes  ?  No : 
it  usually  requires  the  aid  of  an  exciting  cause  to 
effect  the  abortion. 

What  may  be  regarded  as  exciting  causes  ?  Mecha- 
nical irritants,  great  muscular  effort,  nauseating,  or 
peculiar  odors ;  the  smell  of  segars  the  odor  of  flow- 
ers, &c.,  under  some  circumstances  produce  this  effect. 

Is  the  production  of  abortion  always  within  the 
power  of  the  mother  ?  Not  always  ;  some  women  are 
unable  to  produce  it,  however  they  wickedly  attempt 
it,  by  jumping,  standing,  taking  active  medicines,  &c. 

What  is  the  most  certain  mode  of  effecting  abortion  ? 
By  rupturing  the  membranes,  and  allowing  the  fluids 
to  escape. 

How  are  you  to  explain  the  action  of  the  causes  of 
abortion  ?  They  must  produce  first  organic  irritation 
in  the  blood  vessels  of  the  uterus,  and  this  must  extend 
to  the  muscular  tissue  of  the  organ. 

What  distinction  are  you  to  make  between  irritation 
of  the  blood  vessels,  and  that  of  the  muscular  fibres  of 


406  PHYSIOLOGY   AND    PATHOLOGY 

the  uterus  ?  It  has  been  explained  thus,  according  to 
the  theory  of  Bichat :  irritation  of  the  blood  vessels 
involves  merely  the  organic  life  ;  irritation  of  the  ute- 
rine fibre  involves  the  animal  life — hence  when  irrita- 
tion of  the  blood  vessels  occurs,  there  is  not  necessa- 
rily any  contraction,  but  when  irritation  of  the  uterine 
or  muscular  fibre  occurs,  there  will  be  contractions, 
and  perhaps  also  expulsion.  This  however  is  to  be 
understood  as  a  speculation. 

Will  contraction  of  the  uterine  fibres  arrest  hem- 
orrhage so  long  as  the  ovum  is  retained  ?  No  :  if  the 
ovum  be  detached,  it  is  usually  a  cause  of  hemorrhagic 
irritation. 

Suppose  however  you  have  a  partial  detachment  of 
the  ovum,  can  the  hemorrhage  be  arrested  before  the 
ovum  be  expelled  ?  It  may  in  consequence  of  the  co- 
agulation of  blood  in  the  orifices  of  the  vessels,  provided 
the  surface  of  the  detachment  be  not  too  large. 

SYMPTOMS  OF  ABORTION. 

What  are  the  symptoms  of  abortion?  Sense  of 
weight,  and  pain  in  the  pubic  and  sacral  regions, 
more  or  less  muco-sanguineous  secretion  escaping  from 
the  vulva,  &c. 

Can  you  diagnosticate  between  abortion  and  dys- 
menorrhoea,  during  the  first  three  months  of  supposed 
pregnancy  ?  Not  with  any  confidence,  even  in  some 
cases  after  the  mass  within  the  uterus  has  been  extruded. 

What  are  usually  regarded  as  the  diagnostic  signs 
of  abortion  ?  Regular,  intermitting  pain  in  the  back  ; 
hemorrhage  to  some  extent ;  more  or  less  watery  dis- 
charge ;  strong  bearing  down,  expulsive  pains :  most 
or  all  of  these,  except  the  watery  discharge  are  met 
with  in  dysmenorrhoea. 

Does  abortion  always  become  complete  when  once 
begun  ?  Not  always ;  the  ovum  may  sometimes  be 
preserved  in  a  state  of  vitality  for  some  length  of  time, 
though  its  development  may  not  increase. 

What  consequences   result  from   abortion  ?     They 


OF   THE   HUMAN    FEMALE.  407 

arc  very  various  ;  some  women  recover  well  and  enjoy 
even  better  health  after  one  abortion,  but  others  suffer 
ill  health,  during  a  part  or  all  the  remainder  of  their 
lives,  especially  when  the  death  of  the  ovum  has  been 
caused  by  mechanical  violence. 

How  do  you  prevent  abortion  ?  Diminish  the  mor- 
bid irritability,  by  removing  the  cause.  If  plethoric, 
bleed,  &c.  If  too  much  reduced  give  nutritious  food, 
tonics,  &c.     Keep  the  patient  quiet. 

What  are  habitual  abortions  ?  A  recurrence  of  abor- 
tions at  every  pregnancy. 

PREVENTIVE  TREATMENT  IN  CASES  DISPOSED  TO 
ABORTION. 

How  are  you  to  arrest  a  tendency  to  abortion  ? 
By  a  general  antiphlogistic  and  revulsive  plan  of  treat- 
ment, which  diminishes  the  force  of  the  blood  upon 
the  inner  surface  of  the  uterus,  &c. 

Blisters  to  the  back,  &c.,  are  often  useful  in  such 
cases.  Amongst  the  internal  remedies  are  the  sugar 
of  lead,  digitalis,  &c.,  to  diminish  the  force  of  the  cir- 
culation. 

What  valuable  mechanical  means  have  we  at  hand, 
for  the  arrest  of  the  hemorrhage?  The  tampon,  for 
the  purpose  of  arresting  the  flow  of  the  blood  through 
the  vagina. 

What  is  the  best  article  for  the  tampon  or  plug  ? 

Strips  of  bandage,  or  better  still,  a  piece  of  sponge, 
cut  into  an  oblong  shape,  and  so  introduced  as  to 
allow  of  its  expansion  within  the  vagina. 

How  far  may  the  use  of  the  tampon  involve  the  safety 
of  the  ovum  ?  It  has  been  supposed  dangerous  to  it, 
but  this  can  rarely  if  ever  happen,  provided  it  be  pro- 
perly introduced,  and  judiciously  managed. 

What  precautions  are  first  to  be  had  recourse  to  ? 
Beduce  first  of  all,  the  force  of  the  general  circulation, 
by  vascular  depletion,  then  allay  the  pain  by  opiates. 

May  the  ovum  be  detaclied  from  the  surface  of  the 
uterus  ?  It  may  become  detached,  after  the  symp- 
toms have  continued  a  short  time. 


408  PHYSIOLOGY   AND   PATHOLOGY 


WHAT  TO  DO  IF  OVUM  IS  DETACHED. 

How  are  you  to  act  when  you  discover  this  fact  ? 
Encourage  its  complete  expulsion. 

Suppose  you  find  the  ovum  lodged  in  the  orifice  of 
the  uterus,  what  should  you  do  ?  Remove  it,  or  facili- 
tate its  detachment. 

Should  you  give  large  doses  of  opium  in  this  parti- 
cular state  of  things  ?  If  any,  merely  sufficient  to 
allay  the  nervous  irritation,  not  enough  to  paralyse 
the  uterine  contractions. 

Should  you  always  make  an  examination  per  va- 
ginam,  in  case  of  supposed  detachment  ?  Yes,  always, 
carefully. 

HoAv  should  you  proceed  to  eifect  the  complete  re- 
moval of  the  ovum  in  such  cases  ?  By  the  finger,  by 
Dewees'  hook,  or  better  still  by  Bond's  abortion  forceps. 

Does  the  hemorrhage  usually  cease  speedily,  after 
the  removal  of  the  ovum  ?  It  speedily  in  most  cases 
becomes  reduced  to  a  mere  lochial  discharge,  which 
usually  subsides  in  a  very  few  da^^s. 

Upon  what  does  uterine  hemorrhage  depend,  during 
or  immediately  after  labor,  or  for  some  time  before 
labor  begins  ?  Upon  detachment  of  some  portion  of 
the  placenta. 

Where  is  the  placenta  usually  attached  ?  About  the 
fundus,  or  one  of  the  sides  of  the  uterus,  near  one  of 
the  fallopian  tubes. 

What  are  the  consequences  of  the  detachment  of 
the  placenta,  to  both  mother  and  child  ?  Both  are 
endangered  by  it ;  the  mother  suffers  from  the  direct 
loss  of  blood,  and  the  fetus  from  imperfect  hematosis. 
Should  any  lesion  of  the  placenta  occur,  the  fetus 
suffers  from  direct  loss  of  blood,  while  the  mother  may 
escape  accident. 

Is  the  detached  portion  of  the  placenta  ever  re- 
united? It  is  probably  never  re-united  in  such  way 
as  that  the  function  can  be  carried  on  in  the  part  once 
detached. 


OF   THE   HUMAN   FEMALE.  409 

What  becomes  interposed  between  the  placenta  and 
the  internal  surface  of  the  uterus  ?  A  coagulum  of 
blood,  which  may  become  organized  and  adherent  both 
to  the  uterus  and  placenta. 

HYDATIDS  IN  THE  UTERUS. 

What  is  supposed  to  be  the  origin  of  hydatid  form- 
ations, which  sometimes  distend  the  uterus  ?  At  one 
time  they  were  supposed  to  spring  from  mucous  sur- 
face, and  hence,  originate  in  the  lining  membrane  of 
the  uterus.  At  present  the  prevailing  opinion  is  that 
they  depend  upon  the  serous  membranes  for  their 
nutrition,  and  it  has  been  observed,  that  they  are 
rarely  or  ever  found,  except  in  some  way  or  other, 
connected  with  pregnancy.  In  such  cases,  they  are 
usually  first  developed  upon  the  surface  of  the  ovum. 

What  influence  do  they  exert  over  the  development 
of  the  ovum  itself?  When  numerous,  they  interfere 
with  the  nutrition  of  the  ovum,  which  then  blights,  so 
that  upon  extrusion  there  is  little  appearance  of  the 
original  ovum. 

What  are  the  symptoms  of  hydatids  in  the  uterus  ? 
They  considerably  resemble  those  of  ordinary  preg- 
nancy, and  hence,  cannot  be  satisfactorily  diagnosti- 
cated, until  they  begin  to  be  extruded.  Women  af- 
fected with  hydatid  formations  in  the  uterus,  are  rather 
more  liable  to  have  occasional  or  constant  bloody 
serous  discharges  from  the  uterus,  for  a  greater  or 
less  length  of  time,  before  expulsion  takes  place.  In 
the  early  months,  the  diagnosis  is  very  obscure,  but 
when  the  uterus  is  greatly  distended,  physical  explo- 
ration and  ballottement,  prove  the  non-existence  of  a 
fetus  in  utero. 

What  opinions  have  been  entertained,  respecting  the 
dependence  of  hydroraetraupon  hydatids  ?  Dr.  Denman 
regarded  dropsy  of  the  uterus,  as  a  very  large  hydatid. 

Suppose  the  existence  of  hydatids  be  suspected, 
or  even  satisfactorily  made  out,  what  plan  of  treat- 
ment ought  to  be  adopted  ?  As  a  general  rule 
35 


410  PHYSIOLOGY   AND    PATHOLOGY 

it  will  be  proper  to  palliate  any  disturbances  which 
may  occur,  and  then  wait  until  symptoms  of  labor 
come  on,  when  if  the  extrusion  of  the  mass  or  masses 
be  tardy,  administer  ergot  sufficent  to  excite  the  expul- 
sive action  of  the  uterus. 

EXTRA-UTERINE  PREGNANCY. 

What  is  the  second  class  of  pregnancies  usually 
adopted  by  obstetric  writers  ?  Irregular,  abnormal, 
or  extra-uterine  pregnancy. 

Of  how  many  varieties  does  it  consist  ?  1st.  Of 
Ovarian  pregnancy.  2d.  Of  ventral  or  abdominal 
pregnancy.  3d.  Of  tubal  pregnancy.  4th.  Of  inter- 
stitial pregnancy. 

What  is  meant  by  the  term  ovarian  pregnancy  ? 
That  in  which  the  embryo  becomes  developed  in  the 
ovary. 

What  by  ventral  or  abdominal  pregnancy  ?  That 
in  which  the  ovule  or  embryo  becomes  deposited  in 
the  cavity  of  the  abdomen  and  developed  there. 

What  by  tubal  pregnancy  ?  That  in  vfhich  the 
embryo  becomes  developed  in  the  tube. 

What  are  we  to  understand  by  interstitial  preg- 
nancy ?  That  in  which  the  ovule  has  in  some  way  or 
other  become  situated  between  the  layers  of  muscular 
fibres  in  the  uterus,  and  there  acquires  a  degree  of 
development. 

Have  we  any  precise  knowledge  of  the  causes  of 
these  different  varieties  of  extra-uterine  pregnancy  ? 
We  have  no  precise  knowledge  of  the  causes — our  ideas 
are  merely  speculative  on  this  subject.  It  has  been 
ascertained  by  experiment  that  if  the  fallopian  tube 
be  obstructed  by  ligature,  or  by  excision  of  a  portion 
of  it,  after  impregnation  and  before  the  ovule  has 
passed  through  its  canal,  it  becomes  unable  to  arrive 
at  the  uterus,  and  it  may  be  somewhat  developed  in  the 
ovary  or  tube  as  a  consequence,  &c. 

Does  the  development  of  the  fetus  go  on  in  the 


OF   THE   nUMAN    FEMALE.  411 

body,  or  at  the  surface  of  an  ovary?  At  the  surface, 
and  rarely,  if  ever,  in  the  body. 

What  then  are  the  investments  of  the  embryo? 
Amnion,  chorion,  and  peritonaeum,  and  probably  ad- 
ventitious membranes. 

Upon  what  does  abdominal  pregnancy  probably  de- 
pend ?  Upon  irregular  action  of  the  tubes ;  the 
morsus  diaboli  not  embracing  or  retaining  the  ovum. 

What  is  the  process  by  which  the  ovum  forms  a 
nidus  in  which  to  be  developed  ?  Its  presence  in  the 
cavity  of  the  peritonasum  probably  excites  inflamma- 
tion and  an  effusion  of  coagulable  lymph,  which  sur- 
rounds the  ovum,  as  the  decidua  would  in  the  cavity 
of  the  uterus. 

Upon  what  does  tubal  pregnancy  possibly  depend  ? 
Upon  stricture  of  the  tube,  preventing  the  passage  of 
the  ovum  into  the  cavity  of  the  uterus. 

What  in  this  case  are  the  investments  of  the  em- 
bryo ?     Amnion,  chorion,  and  parietes  of  the  tube. 

Can  interstitial  pregnancies  be  satisfactorily  ac- 
counted for  ?  Not  at  all,  unless  under  the  supposi- 
tion that  when  the  ovum  reaches  the  parietes  of  the 
uterus  in  the  tubes,  it  is  arrested  at  that  point  and 
ulcerates  its  way  into  the  substance  of  the  walls  of 
the  organ. 

For  what  length  of  time  may  the  ovum  continue  to 
develop,  in  these  cases  of  extra-uterine  pregnancy  ? 
For  one  or  two  months,  though  in  some  cases  much 
longer. 

What  usually  becomes  of  it  after  that  time  ?  It 
usually  dies,  becomes  encysted  in  its  own  membranes, 
then  gradually  converted  into  a  sebaceous  matter,  and 
looks  as  though  it  had  been  kept  in  spirits. 

Is  it  subject  to  decomposition  while  thus  encysted? 
It  rarely  becomes  decomposed  unless  the  cavity  of  the 
cyst  is  exposed  to  atmospheric  air. 

Are  the  placenta  and  cord  mostly  found  appended  to 
the  embryo  in  these  cases  ?  In  all  cases  where  there 
is  any  degree  of  general  development. 


412  PHYSIOLOGY    AND    PATHOLOGY 

What  substitutes  the  decidua  ?     Coagulable  lymph. 

What  is  the  condition  of  the  cavity  of  the  uterus 
in  these  cases  ?  It  is  always  furnished  with  a  decidua. 

Does  this  decidua  remain  in  the  uterus  as  long  as 
the  embryo  remains  in  the  pelvis  or  abdomen  ?  Not 
usually — it  is  sometimes  thrown  off  in  a  few  months. 

Do  any  inconveniences  result  to  the  mother  in  those 
ca'&es  in  which  the  fetus  lives  and  continues  to  be  de- 
veloped ?  Serious  consequences  usually  ensue ;  irri- 
tation, inflammation,  suppuration,  ulceration,  and 
sloughing,  are  all  liable  to  take  place ;  sometimes  to 
an  extent  to  cause  the  death  of  the  mother. 

What  kind  of  accident  may  accompany  the  rupture 
of  the  cyst,  and  cause  the  immediate  death  of  the 
mother  ?     Profuse  hemorrhage. 

If  death  do  not  happen  from  this  cause  what  may 
produce  it  more  tardily  ?     Peritongeal  inflammation. 

Do  any  instances  occur,  in  which  the  fetus  becomes 
considerably  developed,  without  causing  fatal  irrita- 
tion ?  There  are  instances  on  record  in  which  the  wo- 
man has  carried  such  a  fetus  many  years. 

What  then  usually  happens  about  the  end  of  the 
ninth  month  ?  A  parturient  effort  takes  place,  and 
sometimes  the  decidua  and  some  coagula  are  thrown 
off;  uterine  action  then  subsides. 

Does  the  patient  ever  recover  after  such  parturient 
efforts  ?  Some  women  live  many  years  after  such  an 
event. 

Is  it  possible  for  them  to  have  a  true  pregnancy 
while  they  are  carrying  the  product  of  extra-uterine  con- 
ception ?  Some  cases  of  this  kind  are  on  record,  and 
there  is  no  reason  why  pregnancy  should  not  recur 
after  the  decidua  has  been  discharged  from  the  cavity 
of  the  uterus  ? 

What  is  the  more  common  result  ?  Irritation,  fol- 
lowed by  inflammation  and  abscess,  opening  exter- 
nally, as  at  the  umbilicus,  groin,  pcrinseum,  or  into 
the  intestines. 

What  are  the  symj)toms  of  extra- uterine  pregnancy  ? 


OF   THE   HUMAN    FEMALE.  413 

They  are  very  irregular,  and  differ  somewhat  from 
those  of  normal  or  uterine  pregnancy. 

What  takes  place  in  regard  to  the  catamenia  ?  It 
mostly  returns  at  the  usual  period  of  quickening,  and 
then  continues  regular,  especially  if  the  decidua  have 
been  thrown  off. 

What  is  the  condition  of  the  mammae  ?  They  mostly 
become  flattened  after  having  been  partially  de- 
veloped. 

Is  there  any  difference  in  the  time  at  which  the 
fetus  is  felt  ?  If  it  acquires  any  muscular  develop- 
ment, it  is  felt  earlier  than  in  natural  pi'egnancy. 

Is  the  ovary  liable  to  take  on  an  effort  at  abnormal 
generation  ?  Yes — it  has  been  known  to  contain  hair, 
teeth,  &c.,  which  were  probably  the  result  of  abnor- 
mal generation. 

What  other  instances  are  known  which  lend  support 
to  the  doctrine  of  emboitment  or  encasement  of  germs? 
The  fact  recorded  (in  Coxe's  Med.  Museum,  vol.  ii. 
No.  2. — Sept.  and  Oct.  1805,)  in  which  a  fetus  was 
found  within  the  abdomen  of  a  boy,  fourteen  years 
old ;  and  the  case  related  by  Velpeau,  where  the  ru- 
diments of  a  fetus  were  engrafted  on  the  testicle  of 
a  male,  &c.  Blundell  saw  an  "  imperfectly  developed 
fetus,  about  the  size  of  six  or  seven  months,  and 
which  was  taken  from  a  boy,  where  it  lay  in  a  sac  in 
communication  with  the  child's  duodenum,  the  buy 
being  pregnant." 

TREATMENT  IN  EXTRA-UTERINE  PREGNANCY. 

What  are  the  indications  for  treatment  of  extra- 
uterine pregnancies  ?  Generally  palliative,  to  relieve 
or  remove  irritation  as  much  as  possible. 

What  is  to  be  done  when  the  cyst  is  ruptured  ? 
Support  the  patient's  strength  by  tonics,  cordials,  &;c. 

Suppose  an  abscess  should  form  and  point  exter- 
nally ?     Apply  fomentations,  poultices,  &c. 

Would  it  be  advisable  to  open  an  abscess,  if  it  could 
be  reached  by  an  incision  ?  By  good  authority,  it  is 
35* 


414  THE    OVUM,  EMBRYO   AND   FETUS 

thought  that  it  would  be  best  to  make  a  free  inci- 
sion, to  evacuate  the  contents  of  the  abscess,  and  thus 
remove  the  irritation. 

Would  it  be  proper  to  favor  the  removal  of  the  con- 
tents of  the  abscess  bj  injecting  it  with  cleansing 
washes  ?  This  would  probably  greatly  facilitate  the 
restoration  of  the  patient's  health. 

Is  the  placenta  mostly  adherent  to  some  part  of 
parieties  of  the  abscess  ?  It  is  usually  attached 
strongly  to  some  portion  of  the  wall  of  the  sac. 

How  is  it  to  be  separated  ?  By  washing  away  the 
debris,  as  fast  as  it  sloughs. 

Would  gastrotomy  be  advisable  in  the  early  stage 
of  abdominal  pregnancy  ?  The  opinion  is  entertained 
by  some  that  it  would  be  safer  for  the  mother  that  it 
be  done,  and  thus  protect  her  against  subsequent  irri- 
tation. 

THE  OVUM,  EMBRYO,  AND  FETUS  LIABLE  TO  ACCIDENTS 
WHILE  IN  UTERO. 

Is  the  ovum,  the  embryo,  or  the  fetus  liable  to  any 
accidents  while  in  utero  ?  The  product  of  conception 
has  been  observed  to  be  incident  to  various  accidents, 
resulting  in  modification  by  excess,  or  diminution  of 
parts,  or  disarrangement  of  the  various  organs.  These 
accidents  have  been  classed  under  the  general  epi- 
thet of  monstrosity.  Thus  the  ovum  has  become  one 
immense  hydatid,  or  a  number  of  the  cells  of  the  pla- 
centa have  taken  on  this  modified  action,  and  there 
has  resulted  a  congeries  of  cells  filled  with  fluid,  va- 
ried in  size,  w^hich  congeries  has  been  called  by  Ma- 
dame Boivin,  Hydatideengrappe,  or  grape-like  hyda- 
tids. The  influence  of  this  accident  to  the  placenta 
upon  the  embryo  has  been  various — sometimes  blight- 
ing its  growth  very  perceptibly,  so  that  when  the  con- 
tents of  the  uterus  were  thrown  ofl",  it  has  been  found 
imperfect  and  shrivelled,  or  in  some  cases  it  could  not 
be  seen  at  all,  having  probably  died  and  been  dis- 
solved in  some  of  the  fluids.     In  other  instances  the 


LIABLE   TO    ACCIDENTS   WHILE   IN    UTERO.       415 

"wliole  ovum  has  been  converted  into  a  solid  substance 
resembling,  when  cut  open  after  being  thrown  off,  a 
firm  clot  of  blood.  Such  discharged  masses  have  re- 
ceived the  popular  name  of  moles.  Again  the  con- 
tents of  a  gravid  uterus  may  undergo  changes  which 
result  in  the  defect  of  development,  and  when  thrown 
off  at  various  periods  of  the  gestation,  are  found  to 
hold  but  faint  resemblance  to  the  normal  product  of 
conception  in  the  human  female.  Besides  this,  it  oc- 
casionally happens  that  two  ova  fecundated  at  the 
same  time,  and  passing  into  the  uterus  in  a  healthy 
condition,  by  some  accident  become  so  fused  together 
at  different  points,  as  in  some  cases  to  appear  as  one 
child  with  two  heads,  or  with  four  arms,  or  with  four 
legs,  or  with  two  apparently  perfect  persons  fastened 
to  each  other  at  some  small  point  which  enabled  each 
to  obey,  to  some  extent,  its  own  instincts,  as  was  illus- 
trated in  the  case  of  Ritta  and  Christina,  reported  by 
European  writers,  as  well  as  the  case  of  the  "  Siamese 
Twins"  seen  in  America  by  very  many  citizens  but  a 
few  years  since.  Although  there  have  been  numerous 
instances  of  various  kinds  of  monstrosity  reported  at 
different  periods  through  a  long  series  of  years,  we  are 
not  aware  that  there  has  been  any  systematic  account 
or  classification  of  these  departures  from  the  ordinary 
laws  of  formation,  since  between  the  years  1832  and 
1837,  when  Isidore  Geoffrey  Saint  Ililaire,  publislicd 
his  very  interesting  and  instructive  Histoire  Gdnerale 
et  Particuliere  des  Anomalies  de  ['Organisation  chez 
L'Homme  et  les  Animaux  ;  Ouvrage  Comprenant  des 
Recherches  surles  Caracteres,la  Classification,  I'lnflu- 
ence  Physiologique  et  Pathologique,  les  Rapports  Q6- 
n^raux,  les  Lois  et  les  Causes  des  Monstruositds,  des 
Vari^tds  et  des  Vices  de  Conformation,  ou  Traite  de 
Teratologic — a  work  which  all  medical  men  should 
read.  Dr.  Meigs  has  also  collected  the  history  of 
a  few  cases  which  have  occurred  in  this  country. 
In  the  winter  of  1850-1,  I)r.  Pemberton  Thorn,  a 
pupil  of   the  Philadelphia    Obstetric   Institute,  while 


416  THE   OVUM,    EMBRYO   AND   FETUS 

attending  upon  one  of  the  patients,  found  her  with 
four  feet  offering  at  the  vulva,  which  when  de- 
livered were  discovered  to  belong  to  two  female 
children,  who  had  been  subjected  to  this  process  of 
fusion  to  such  extent  as  to  have  the  two  heads  and 
two  thoraxes  united  apparently  into  one,  so  that  there 
was  but  one  face,  two  perfect  and  two  imperfect  ears ; 
four  well  developed  thoracic  members,  two  distinct 
abdomens,  each  with  its  umbilical  cord,  placenta  and 
pelvic  members. 

The  injection,  dissection,  anatomical  preparations 
and  the  description  were  performed  by  the  dex- 
trous hands  of  Dr.  John  Neill,  the  curator  of  the 
College,  and  the  artistic  representations  were  executed 
under  his  supervision. 

What  are  the  description  and  illustration  of  this 
subject  as  published  in  No.  2,  of  Quarterly  Summary 
of  the  Transactions  of  the  College  of  Physicians  of 
Philadelphia,  from  January  to  April  inclusive,  1851  ? 

No.  46,  Skeleton  of  a  double-bodied  monster,  and 
No.  47,  Alimentary  canal,  respiratory  organs,  &c., 
of  the  same,  presented  by  Dr.  Warrington. 

In  the  dissection  and  preparation  of  the  specimen, 
the  following  peculiarities  were  observed. 

Exterior, — The  general  appearance  is  that  of  two 
children,  having  a  thorax  in  common,  with  a  single  " 
head.  By  referring  to  the  accompanying  drawing,  it 
will  be  seen  that  the  head  is  apparently  single,  and 
that  the  face  presents  no  peculiarity  but  a  fissure  of 
the  lower  lip  in  the  median  line.  On  the  back  of  the 
head,  which  w^as  very  wide,  there  was  a  symmetrical 
double  ear,  the  meatus  of  which  was  imperforate. 

The  thorax  was  single,  common  to  the  two  bodies. 
Upon  its  exterior  were  four  nipples,  two  of  which 
are  seen  in  the  drawing,  the  other  two  were  in  the 
same  position  on  the  corresponding  part  of  the 
thorax.  There  were  four  upper  extremities,  all  of 
w^hich  were  perfect,  equally  developed,  and  natural 
in  their  positions. 


LIABLE   TO    ACCIDENTS   WHILE   IN    UTERO.       417 

Below  the  umbilicus  the  separation  was  complete. 
The  lower  part  of  each  body  was  perfect.  The  lower 
extremities  were  of  the  same  size  and  appearance. 

The  cord  was  very  thick,  and  consisted  of  two 
umbilical  veins,  which  were  of  the  same  size,  and 
four  umbilical  arteries,  one  of  which  was  very  large, 
and  the  other  very  small.  At  a  distance  of  two  inches 
from  the  placenta,  which  was  double,  the  cord  bifurcat- 
ed, each  part  entering  its  own  placenta.    See  fig.  143. 

Fig.  143. 


Alimentary  canal, — The  mouth  was  a  single  cav- 


418 


THE    OVUM,    EMBRYO   AND    FETUS 


ity,  containing  two  tongues,  separated  posteriorly  by 
an  irregular  mass  covered  with  skin,  which  was  pro- 
bably a  rudimentary  cheek  or  lip.  The  fauces  and 
upper  part  of  each  pharynx  were  distinct;  each 
contained  a  uvula  and  two  tonsils.  The  pharynges 
communicated,  and,  from  the  funnel-shaped  cavity 
formed  by  their  junction,  there  proceeded  a  single 
oesophagus. 

The  oesophagus  terminated  in  a  stomach  containing 
a  single  cavity,  though  its  shape  was  such  as  to  give 
the  idea  that  two  stomachs  had  been  fused  by  their 
lesser  curvatures.  The  antrum  pylori  is  plainly  seen 
on   either  side    in  fig.  144,  in  which  T,  represents 


the  tongues;  ^,  trachea;  L,  lungs ;  H,  rudimentary 
heart ;  S,  stomach  ;  E,  intestine ;  J,  bifurcation ;  C, 
colon. 

From  the  pylorus  there  extended  a  single  intesti- 
nal canal  which,  at  u  distance  of  two  feet  from  the 


LIABLE   TO    ACCIDENTS   WHILE   IN    UTERO.      419 

storaacli,  divided  into  two  distinct  tubes,  each  about 
fifteen  inches  in  length.  These  had  all  the  charac- 
ters of  the  small  intestine,  and  terminated  regularly 
at  the  ileo-colic  valve.  The  large  intestine  was  com- 
pletely double,  there  being  one  for  each  child  ;  each 
was  perfect  from  the  coecum  to  the  anus,  not  except- 
ing the  appendix  vermiforis,  and  contained  the  usual 
amount  of  meconium. 

The  liver  was  single,  large,  and  symmetrical.;  it 
contained  two  lobes  of  about  the  same  size,  and  a 
single  gall-bladder.  The  spleen  and  two  well- formed 
kidneys  were  found  in  each  trunk.  The  genitals, 
which  were  female,  were  perfectly  developed  both  ex- 
ternally and  internally  in  each  pelvis. 

Organs  of  Respiration. — The  larynx  opened  in  the 
usual  position  in  each  pharynx,  and  the  trachea  and 
bronchial  tubes  were  regularly  developed  for  each 
body.  The  lungs  were  four  in  number;  those  be- 
longing to  the  right  child  had  a  large  vessel  entering 
directly  at  the  apex. 

Circulation. — There  were  two  hearts ;  one  was 
rudimentary  and  situated  between  the  lungs  of  the 
left  child ;  it  was  conical  in  its  shape,  consisted  of  but 
one  single  cavity,  and  from  its  base  there  proceeded 
a  single  vessel.  The  other  was  developed  irregularly, 
(fig.  145 ;)  it  was  situated  under  the  sternum,  to  which 
are  articulated  the  right  ribs  of  the  right  child,  and 
the  left  ribs  of  the  left  child.  From  the  base  of  this 
heart  there  arose  an  aorta  for  each  child,  which  oc- 
cupied its  usual  position  on  the  vertebral  column. 
The  larger  arterial  branches  were  regularly  given  off, 
with  the  exception  of  the  umbilical  arteries  of  the 
right  child,  one  of  which  was  very  large  and  appeared 
to  be  the  continuation  of  the  primitive  iliac ;  the  other 
was  exceedingly  small. 

The  ascending  vena  cava  of  the  left  child  did  not 
pass  through  the  liver,  but,  after  being  joined  by  the 
descending  vena  cava,  the  common  trunk  thus  formed 
passed   behind  the    heart,    emptying  into   the  right 


420 


THE  OVUM,  EMERY 0  AND  FETUS 


auricle.  The  ascending  vena  cava  of  the  right  child 
did  not  seem  to  exist  below  the  liver,  but  the  blood- 
vessels from  the  lower  extremities  opened  into  the 
portal  vein,  which  was  large  proportionally.  The 
pulmonary  artery  communicated  with  each  aorta. 
See  fig.  145,   in  which  H,  represents  the  heart ;  A, 

Fig.  145. 


pulmonary  artery  ;  aor,  aorta  ;  Y  C,  ascending  vena 
cava  of  right  body  ;  P,  portal  vein  ;  U,  umbilical 
veins  ;  u  a,  umbilical  arteries  ;  L,  liver  ;  D  V  C, 
descending  vena  cava  of  left  body ;  A  V  0,  ascend- 
ing vena  cava  of  left  bod}^ 

Skeleton. — The  skeleton  measured  thirteen  inches 


LIABLE  TO   ACCIDENTS   WHILE   IN   UTERO.      421 

after  it  had  been  prepared  and  dried.  The  head 
measured  four  inches  in  its  occipito-mental  diameter, 
and  three  and  a  half  inches  in  its  bi-parietal.  The 
anterior  and  superior  surface  of  the  head  was  single ; 
the  duplication  commenced  at  the  base  of  the  cranium. 
The  bones  of  the  face  are  those  of  a  single  head, 
with  the  exception  of  an  effort  at  a  double  forma- 
tion of  the  inferior  maxillary  bone  and  of  the  palate 
processes  of  the  superior  maxillary.  The  frontal  and 
parietal  bones  were  those  of  a  single  head,  but  there 
were  two  occipital  bones ;  to  the  condyloid  processes 
of  each  were  articulated  the  atlas  of  each  vertebral 
column.  There  were  four  temporal  and  two  imper- 
fect sphenoid  bones.  See  fig.  146,  in  which  P, 
represents  the  parietal  bone ;  W,  w^ormian  bones ; 
0,  occipital  bones ;  T,  temporal  bones ;  L,  lateral 
portion  of  the  occiput. 

Fig.  146. 


Below  the  head,  the  skeleton  was  completely  dou- 
ble. The  thorax  was  a  single  cavity  having  two 
sterna,  to  which  the  ribs  and  clavicles  were  articu- 
lated in  a  very  peculiar  manner.  The  right  ribs 
and  clavicle  of  the  right  skeleton,  and  the  left  ribs 
and  clavicle  of  the  left  skeleton,  articulated  with  the 
80 


422  THE    OVUM,    EMBRYO    AND    FETUS 

anterior  sternum.  The  left  ribs  and  clavicle  of  the 
right  skeleton,  and  the  right  ribs  and  clavicle  of  the 
left  skeleton,  articulated  with  the  posterior  sternum. 

In  other  respects,  the  bones  of  each  skeleton  were 
developed  and  articulated  as  usual.     See 

Fig.  147. 


DU.  WEST'S  CASE  OF  MONSTROSITY. 

What  is  the  description  and  illustration  given  by 
Dr.  Francis  West,  Jr.,  of  Philadelphia,  of  an  anence- 
phalous  fetus  born  under  his  care,  and  reported  by 


LIABLE   TO   ACCIDENTS    WHILE   IN    UTERO.       423 

him  in  vol.  i.  of  the  Medical  Examiner  ?  In  the  fol- 
lowing brief  and  imperfect  sketch,  I  have  attempted 
only  to  delineate  the  more  characteristic  features  of 
this  interesting  specimen  of  monstrosity,  leaving  to 
others  to  explain  the  causes  of  their  occurrence,  and 
to  fix  their  precise  value  and  importance.  It  is  a  per- 
fect specimen  of  what  has  been  thought  by  the  learned 
author  of  the  article  "  Anencephalous,"  in  the  Ameri- 
can Cyclopaedia  of  Pract.  Med.  and  Surgery,  to  be 
the  rarest  form  of  this  kind  of  abnormal  deviation, 
and  the  only  one  to  which  the  term  can  be  appro- 
priately applied — "  So  seldom  does  it  occur,"  he  adds, 
"  that  only  a  few  cases  of  it  are  to  be  found  on  re- 
cord."— Some  remarkable  peculiarities  of  external 
configuration  and  structure  exist  along  with  the  entire 
absence  of  the  cerebro-spinal  axis,  which  give  to  the 
specimen  before  us  increased  value  and  curiosity.  By 
some  very  essential  and  radical  vice  of  formation,  the 
human  fetus  may  become  so  materially  degraded  in  the 
scale  of  being,  as  very  closely  to  approximate,  in  some 
prominent  points,  the  lower  order  of  animals ;  and  I 
may  state  that  its  peculiar  configuration  and  structure 
would  not  by  any  possibility  have  permitted  it  to  as- 
sume the  erect  position,  supposing  it  capable  of  main- 
taining an  independent  existence.  In  obedience  then 
to  this  necessity,  which  I  think  will  be  perfectly  ap- 
parent from  what  follows,  it  has  been  represented, 
in  the  accompanying  drawing,  in  the  horizontal  posi- 
tion, and  not  with  the  view  of  adding  grotesqueness 
to  its  other  singularities.  This  anencephalous  fetus 
possesses  all  the  characters  belonging  to  the  varieties, 
"  Anencephalus  "  and  "  Derencephalus  "  in  Geoffroy 
St.  Hilaire's  classification  of  monsters.  The  cranial 
bones  which  have  been  thought  always  to  exist,  though 
sometimes  only  in  a  rudimentary  condition  in  fetuses 
of  this  kind,  are  here  entirely  absent.  The  basilar 
process  of  the  occipital  bone  is  united  with  the  bodies 
of  the  dorsal  vertebrae,  the  intervening  cervical  ones 
i  ivinaj  no  existence ;  these  vertebrse  and   those  be- 


424 


THE    OVUM,  EMBRYO   AND   FETUS 


low  them  to  the  termination  of  the  column,  are  "  cleft 
posteriorly  and  enlarged  by  spina  bifida,  with  their 
lateral  halves  much  inflected  outwards  and  separated 
from  each   other."     This  condition  of  the  vertebrae 

Fig.  148. 


leaves  a  large  chasm  in  the  back,  about  14  lines  wide, 
covered  only  by  the  membranous  semi-circular  sac, 
represented  in  the  draAving.  The  whole  face  with 
each  individual  organ  of  sense  is  much  enlarged,  and 
presents  a  most  unnatural  expression  of  countenance. 
The  direction  of  the  eyes  as  well  as  tlie  whole  face, 
in  consequence  of  the  excessive  posterior  inclination 
of  the   base  of  the  cranium,  is  immediately  upwards, 


LIABLE   TO   ACCIDENTS   WHILE   IN    UTERO.       425 

even  more  so  than  is  shown  in  the  drawing,  when  the 
fetus  is  held  in  the  erect  position,  which  therefore 
must  have  been  attended  by  their  total  uselessness. 
To  the  whole  margin  of  the  chasm  in  the  back,  which 
at  the  angle  formed  by  the  junction  of  the  basilar 
portion  of  the  skull  to  the  dorsal  vertebrae  becomes  a 
triangular  cavity  of  some  depth,  is  attached  the  sac 
above  mentioned,  which  is  continued  forwards  on 
either  side  along  the  edge  of  the  oblique  plane  formed 
by  the  base  of  the  cranium  and  the  bones  of  the  face. 
This  sac  which  was  filled  with  fluid  was  ruptured  dur- 
ing labor ;  it  enclosed  the  membranous  cornua,  to  be 
seen  in  the  drawing,  and  which  alone  occupied  all  the 
space  upon  which  should  have  rested  the  cerebral 
mass.  Along  the  margin  of  this  bag  throughout  its 
whole  extent  from  the  orbits  to  its  termination  at  the 
sacrum,  is  an  abundant  growth  of  very  dark  hair,  at 
some  points  more  than  half  an  inch  long, — which  ar- 
rangement gives  the  idea  of  the  scalp  having  been  drawn 
over  the  back,  and  countenances  the  notion  that  the 
head  with  its  contents  or  something  answering  to 
them,  were  to  have  been  developed  upon  the  back, 
which  displays  to  all  appearance  the  attempt  to  form 
there  a  lodgment  for  them.  The  above  impression  is 
very  strongly  forced  upon  us  by  a  posterior  view  of 
these  parts  as  they  exist  in  the  preparation,  which 
could  not  be  given  in  the  drawing.  Portions  of  the 
membranes  of  the  medulla  spinalis,  forming  elongated 
circular  sacs,  containing  a  little  thin  fluid,  existed 
upon  and  in  close  contact  with  the  depression  along 
the  bodies  of  the  vertebrae.  The  upper  and  lower  ex- 
tremities present  remarkable  peculiarities  which  de- 
serve special  attention  in  our  observations  and  reflec- 
tions upon  the  character  and  destination  of  this  much 
deformed  being.  The  clavicles  do  not  exist  at  all  : 
and  the  scapulae  in  actual  contact  with  the  sides  of 
the  face,  are  attached  to  the  fore-part  and  sides  of 
the  thorax,  instead  of  posteriorly,  with  their  long  dia- 
meters perpendicular  to,  instead  of  parallel  with  the 
36* 


426  THE    OVUM,   EMBRYO   AND    FETUS 

axis  of  the  body ;  the  arms  and  fore-arms  are  of  un- 
usual length  and  very  loosely  articulated  at  the  carpo- 
radial  articulation ;  the  deltoid  muscles  are  extraordi- 
narily developed,  and  the  skin  of  these,  as  well  as 
that  of  the  lower  extremities  has  much  hair  growing 
upon  it;  the  lower  extremities  are  also  very  long  and 
muscular,  and  present  the  same  peculiarity  of  direc- 
tion as  the  upper  ones  at  their  union  with  the  body. 
The  articulations  at  the  ankles  are  very  loose  and  ad- 
mit without  the  least  violence  the  touching  of  the 
metatarsus  and  the  spine  of  the  tibia  as  the  foot  rests 
upon  a  plane  surface.  Whole  length  of  fetus  from 
heel  to  base  of  cranium,  11  inches;  from  anus  to  base 
of  cranium,  5  inches ;  from  external  malleolus  to  tro- 
chanter, 6  inches  ;  length  of  femur,  3  inches  and  6 
lines ;  length  of  tibia,  2  inches  and  9  lines ;  length 
of  foot,  2  inches  and  3  lines ;  length  of  whole  arm,  8 
inches ;  length  of  humerus,  3  inches  and  3  lines ; 
length  of  fore-arm,  4  inches  and  9  lines.  The  nerves 
of  the  extremities  are  fully  developed,  and  ramify 
through  the  parts  to  which  they  are  respectively  sent. 
On  tracing  up  these  nerves  they  were  found  suddenly 
to  terminate  at  the  vertebrae  and  had  no  connexion 
with  the  spinal  membranes  spoken  of.  This  fact  is  of 
importance  to  those  who  contend  that  the  nerves  are 
formed  at  the  periphery  of  the  body  and  are  de- 
veloped towards  the  central  masses,  with  which  they 
afterwards  unite.  One  or  two  ganglions  of  the  sym- 
pathetic nerve  were  discovered  in  the  thorax,  and  its 
dissection  was  not  further  pursued.  The  umbilical 
cord  is  about  IJ  inches  in  diameter,  and  contains  the 
entire  liver,  which  is  closely  adherent  to  its  sides,  with 
a  large  portion  of  the  great  and  small  intestines. 
The  other  organs  of  the  abdomen  are  natural  and  in 
situ,  and  so  are  those  contained  in  the  thoracic  cavity. 
It  was  desired  to  pursue  particularly  the  dissection  of 
the  nerves  of  animal  life,  but  as  this  would  materially 
have  destroyed  the  preparation,  the  examination  was 
reluctantly  given  up,  and  it  is  hoped  without  the  sa- 


LIABLE   TO   ACCIDENTS   WHILE    IN    UTERO.       427 

crifice  of  much  information.  The  parents  are  natives 
of  Lincolnshire,  England,  and  were  married  in  June 
last,  exactly  six  months  before  the  woman  aborted 
with  this  monstrous  fetus.  The  father  is  about  25, 
and  the  mother  28  years  of  age ;  they  are  perfectly 
•healthy  and  well  formed.  They  arrived  at  a  hotel  in 
this  city  much  fatigued  by  a  forced  journey  which 
they  had  made  from  Cincinnati,  and  the  mother  was 
very  soon  after  taken  sick.  I  reached  her  just  after 
the  w^aters  had  been  discharged,  and  found,  on  exami- 
nation, the  chin  of  the  child  presenting  at  the  inferior 
strait :  a  very  few  pains  sufficed  to  deliver  it.  The 
umbilical  cord  and  placenta  were  much  diseased,  and 
of  the  latter  small  pieces  continued  to  come  away 
for  several  days,  producing  each  time  alarming  he- 
morrhage, which  jeoparded  the  life  of  the  woman. 
She  ultimately,  however,  recovered  perfectly,  and  left 
the  city 

Is  the  welfare  of  the  fetus  ever  compromised  by  the 
accident  of  having  the  cord  encircle  the  neck,  one  or 
more  times  ?  Fetuses  at  birth  are  sometimes  found 
dead.  Under  such  circumstances,  though  probably  not 
so  much  from  the  fact  that  the  cord  by  its  pressure 
interrupts  the  circulation  through  the  brain,  directly, 
as  that  it  is  itself  so  compressed  as  to  cut  off  the  ne- 
cessary connexion  with  the  placenta. 

Is  the  life  of  the  fetus  ever  endangered  by  such 
evolutions  in  the  uterus  as  tie  the  cord  into  close 
knots  ?  The  life  of  the  fetus  is  even  sometimes  de- 
stroyed by  the  tension  by  which  the  cord  is  drawn 
when  thus  knotted,  since  in  such  instances  the  vessels 
have  been  found  nearly  or  quite  obliterated. 

Does  any  inconvenience  ever  result  from  the  coil- 
ing of  the  umbilical  cord  aroui:)d  the  limbs  of  the  fe- 
tus ?  Such  circumstances  have  been  known  to  cause 
atrophy  and  sometimes  even  an  amputation  of  the 
member  which  it  encircled,  see  figs.  149,  and  150.    , 

What  Irish  author  has  given  the  fullest  account  of 


428  THE   OVUM,  EMBRYO    AND    FETUS 

this  spontaneous  amputation  of  the  limbs  of  the  fetus 
in  utero  ?     Probably  Dr.  Montgomery  of  Dublin. 

Fig.  149.  Fig.  150. 


Is  it  satisfactorily  proved  that  all  the  cases  of  spon- 
taneous amputation  of  the  fetal  members  are  depend- 
ant upon  the  accidental  coiling  of  the  umbilical  cord 
around  them  ?  It  would  be  best,  before  coming  to 
such  a  conclusion,  to  consult  his  entire  paper  on  this 
subject,  and  to  read  attentively  the  cases  he  describes, 
as  well  as  those  he  refers  to  as  having  been  collected 
by  Professor  Simpson  and  others. 

Is  the  fetus  subject  to  any  modification  of  its  nor- 
mal form,  ascribable  to  its  position  in  the  uterus  ? 
Many  cases  occur  in  which  the  shape,  or  the  direction 
of  the  growth  of  the  lower  extremities  particularly, 
appears  to  be  modified  by  the  peculiar  position  of  the 
fetus  in  utero,  or  the  influence  which  the  pressure  of 
the  uterus  may  exert  upon  it.  Hence  the  varieties  of 
bow  legs,  club  feet,  &c. 

To  what  other  accidents  may  the  fetus  be  subjected 
during  its  continuance  in  the  cavity  of  the  uterus  ? 
Many,  as  for  example,  if  the  placenta  becomes  de- 
tached, the  fetus  may  become  atrophied ;  or  even  pu- 
trescent. The  fetus  may  also  be  subjected  in  a  greater 
or  less  degree,  to  certain  diseases  to  which  the  mother  is 


LIABLE  TO  ACCIDENTS  WHILE  IN  UTERO.         429 

incident ;  the  mother  may  have  mild  varioloid  and  the 
fetus  die  of  confluent  small-pox. 

ACCIDENTS  TO  THE  CHILD  DURING  LABOR. 
To  what  accidents  is  the  child  liable  during  the 
maternal  effort  at  parturition  ?  They  are  numerous, 
depending  upon  the  condition  of  the  uterus  in  some 
cases,  and  upon  that  of  the  pelvis,  or  that  of  both 
together,  in  some  other  instances.  Should  the  pla- 
centa be  implanted  over  the  orifice  of  the  womb,  its 
separation  as  the  orifice  dilates,  may  not  only  cut  off 
the  means  of  hematosis  for  the  child,  but  it  may 
and  probably  does  in  some  cases  give  exit  to  the  blood 
of  the  fetus,  so  that  it  may  die  of  actual  hemor- 
rhage from  the  placental  vessels.  If  the  membranes 
should  be  ruptured  in  the  very  early  stage  of  the 
labor,  the  contractions  of  the  fundus  and  body  of  the 
uterus  severe,  and  its  orifice  rigid,  the  fetus,  either  by 
direct  compression  made  upon  itself,  or  by  the  com- 
pression of  the  cord  or  placenta  between  the  uterus 
and  itself,  may  be  greatly  prostrated  or  its  life  en- 
tirely destroyed.  Again  :  if  the  umbilical  cord  should 
become  prolapsed,  and  it  be  not  possible  to  return  it 
to  the  cavity  of  the  uterus  so  that  the  head  of  the 
child  may  descend  first,  the  circulation  may  become 
fatally  arrested,  or  the  fetus,  when  born,  is  with  ex- 
treme difficulty  resuscitated.  When  the  pelvis  is 
faulty  in  its  formation,  so  as  to  be  defective  in  its 
amplitude,  the  brain  may  be  either  fatally  compressed 
or  its  functions  so  far  impaired  that  they  are  after- 
w^ards  a  long  time  in  recovering,  or  are  always  imper- 
fectly performed,  leaving  the  child  susceptible  to  con- 
vulsions or  imbecility,  or  other  forms  of  insanity. 

ASTHENIA  OF  INFANTS  AT  BIRTH. 

What  do  you  mean  by  an  asthenic  condition  of  the 

child  at  birth  ?     That  it  is   feeble,   the   features  are 

shrivelled  and  narrow,  resembling  old  persons.     The 

child  is  blue,  does  not  respire  freely ;  its  circulation 


430  ACCIDENTS   TO   THE    CHILD   AT   BIRTH. 

is  very  feeble  ;  it  groans,  does  not  cry,  nor  seem  to 
make  any  effort  to  breathe,  or  if  it  breathes,  it  does 
so  very  feebly. 

How  should  you  manage  such  a  condition  ?  En- 
deavor to  stimulate  its  respiratory  muscles  by  warm 
bath,  and  cold  douches  alternately  ;  by  dry  heat,  slight 
friction  with  the  end  of  the  fingers ;  do  not  fatigue  it, 
but  w^ash  it  with  warm  alcoholic  fluids,  then  apply 
warm  cloths ;  assist  its  respiration  by  blowing  into  its 
lungs,  &c. ;  give  it  barley  water,  gum  water,  sugar 
and  water,  &c. ;  do  not  let  it  be  fatigued  with  nurs- 
ing ;  take  care  not  to  weary  it  by  dressing  ;  wrap  it 
in  a  warm  flannel  or  in  cotton  wadding,  to  accumu- 
late animal  heat  as  much  as  possible. 

ASPHYXIA  OF  INFANTS  AT  BIRTH. 

What  do  you  mean  by  asphyxia  ?  A  state  of  ap- 
parent death,  in  which  the  child  is  perfectly  motion- 
less, and  either  pale,  or  livid. 

How  many  kinds  of  asphyxia  do  you  recognise  ? 
Two;  simple,  and  congestive  asphyxia. 

What  are  the  common  causes  of  this  state  ?  Pres- 
sure in  the  passage  through  the  pelvis.  Pressure 
on  the  cords  or  the  placenta,  by  arresting  the  circula- 
tion, &c. 

Is  the  brain  of  much  importance  during  intra- 
uterine life  ?  It  does  not  appear  to  be.  The  child 
is  like  a  plant,  appearing  to  have  a  mere  vegetable 
existence  while  in  utero. 

What  causes  operate  often  to  produce  asphyxia? 
Compression  upon  the  cord  around  the  child's  neck : 
knots  in  the  cord  which  may  arrest  its  circulation. 
The  retention  of  the  membranes  over  the  child's  head. 
The  floodings  of  the  large  quantities  of  the  liquor 
amnii  or  blood  over  the  child.  Suffocation  under  the 
bed  clothes,  or  by  the  membranes  around  the  head. 
The  respiratory  organs  clogged  with  mucus,  &c. 

What  evidences  have  we  of  the  state  of  simple 
asphyxia  ?     Pallor,    absence   of   pure  blood   on  the 


ACCIDENTS   TO   THE    CHILD    AT    BIRTH.         431 

surface,  absence  of  respiration.  The  breast,  &c., 
may  have  a  bluish  appearance,  but  other  parts  are 
pallid. 

What  evidences  have  we  of  the  congestive  state  of 
asphyxia  ?  The  face  is  swollen  and  turgid  with  blood. 
There  is  absence  of  respiration  and  circulation ;  the 
whole  surface  is  more  or  less  blue,  and  the  extremi- 
ties cold. 

Are  these  two  distinct  aiFections,  or  are  they  pro- 
bably degrees  of  the  same  condition  ?  It  is  probable 
that  they  are  but  degrees  of  the  same  state. 

How  should  you  treat  asphyxia  ?  Remove  all 
mechanical  impediments  to  the  respiration  or  circula- 
tion ;  place  the  child  free  from  the  cloths,  &c.,  clear 
all  mucus  from  about  its  glottis ;  assist  its  respiration, 
if  it  be  able  to  swallow,  give  it  a  little  fluid  to  wash 
away  the  mucus.  Keep  the  child  connected  with  the 
placenta  as  long  as  any  circulation  exists.  Keep  the 
body  warm,  put  it  into  a  basin  of  warm  water ;  bring 
this  to  the  bed  and  lift  the  child  into  it,  before  the 
placenta  is  removed ;  then  dry  it  at  once  by  warm 
cloths  ;  when  it  comes  out,  use  free  friction  in  this 
case,  about  the  respiratory  muscles  with  towel  or 
hand;  use  brandy,  alcohol,  or  hartshorn  liniments, 
and  also  stimulating  injections  ;  then  dash  on  some 
cold  spirits,  or  cold  water  ;  then  in  a  moment  wipe  it 
off,  and  plunge  it  into  the  warm  bath  again,  &c. 
Imitate  the  process  of  respiration,  by  pressing  the 
thorax  and  abdomen,  alternately  with  the  head  : 
sometimes  breathe  into  the  lungs,  pressing' the  larynx 
slightly  against  the  spine  to  prevent  the  air  from 
passing  through  the  esophagus  into  the  stomach,  if 
you  cannot  soon  'succeed  thus,  use  the  tracheal  pipe 
or  quill  to  convey  the  air  into  the  lungs. 

How  must  this  tube  be  used  ?  Pass  it  along 
the  side  of  the  mouth  and  throat,  over  the  glot- 
tis, and  then  force  in  a  small  quantity  of  your  own 
breath. 

What   can   be   said  of  the  value   of  galvanism   or 


432  ACCIDENTS   TO    THE   CHILD    AT    BIRTH. 

electricity  in  these  cases  ?  They  have  not  generally 
succeeded,  and  the  apparatus  is  rarely  at  hand. 

Are  you  speedily  to  abandon  this  treatment  if  your 
first  efforts  do  not  succeed  ?  By  no  means ;  the 
efforts  must  be  persisted  in  for  half  an  hour,  an 
hour,  or  even  more  before  relinquishing  any  attempts 
to  resuscitate  it ;  and  after  you  have  succeeded, 
oblige  the  nurse  to  continue  frictions  over  the  skin 
for  some  time. 

How  would  you  treat  the  congestive  form  of  the 
affection  ?  The  same  as  before,  adding  some  care  to 
diminish  the  amount  of  blood  in  the  veins  of  the  child. 
Therefore,  do  not  tie  the  cord  ;  for  if  the  symptoms 
be  urgent  cut  the  vein  at  least,  some  say  the  whole 
cord,  and  thus  let  the  blood  escape. 

How  much  blood  may  you  thus  take  away  ?  From 
half  an  ounce  to  an  ounce. 

TUMORS  ON  THE  SCALP  OF  INFANTS  AT  BIRTH. 

Are  children  ever  born  with  tumors  on  the  scalp  ? 
It  not  unfrequently  happens  that  tumors  of  greater 
or  less  size  are  found  on  the  scalp. 

Of  what  character  are  they?  Generally  bloody, 
and  are  of  the  character  of  ecchymosis. 

How  are  they  formed?  Most  likely  by  the  ex- 
cessive pressure  made  upon  the  body  of  the  child 
within  the  uterus  or  pelvis,  the  blood  is  squeezed 
out  into  that  portion  of  the  scalp  which  is  not  so 
compressed. 

May  these  tumors  be  supposed  to  be  fractures  of 
the  cranium  ?  They  may,  and  sometimes  they  strongly 
simulate  fractures  with  depression  of  a  portion  of  the 
bone. 

Are  fractures  of  the  cranium  often  met  with  ? 
They  are  not,  though  the  bones  are  sometimes  in- 
dented by  the  pelvic  bones  during  the  second  stage 
of  labor. 

What  should  you  do  for  the  relief  of  the  tumor  ? 
Apply  cold  lead-water,  &c.,  with  a  view  to  discuss  it. 


SUBJECTS  NOT  YET  TREATED  OF.      433 

Should  you  use  frictions  ?  No  :  because  by  so 
doing  you  may  excite  inflammation  in  the  tumor. 

Suppose  it  is  inclined  to  suppurate,  how  should 
you  do  ?  •  Poultice  it,  and  promote  the  formation 
of  pus. 

Should  you  open  it  freely  ?  It  should  be  freely 
opened,  unless  as  happens  in  some  cases,  absorption 
goes  on  very  rapidly.  If  opened,  it  is  to  be  dressed 
as  a  simple  suppurating  wound. 

What  other  accidents  to  the  child  in  utero,  during 
the  labor  for  its  delivery,  and  for  some  time  after,  its 
birth,  could  you.  describe,  did  time  and  the  capacity 
of  this  volume  permit  ?  Very  many,  as  hair-lip,  cleft 
palate,  deficiency  or  excess  of  members  or  parts, 
difterent  varieties  of  hernia,  exstrophies,  atrophies, 
&c.,  &c.,  and  in  relation  to  the  accidents  after  birth, 
as  the  several  diseases  of  the  skin ;  the  morbus  cae- 
ruleus,  or  cyanosis  neonatorum,  and  other  affections 
of  the  vascular  system  ;  the  various  disorders  of  the 
digestive  apparatus,  &c.,  all  of  which  may  hereafter 
be  disposed  of  as  may  be  necessary  and  desirable. 

Has  the  subject  of  the  diseases  of  women  been  ex- 
hausted in  the  course  of  the  present  inquiries? 
While  those  to  which  women  are  incident  during  the 
menstrual  and  pregnant  conditions  have  been  but 
cursorily  examined  and  treated  of,  it  is  not  pretended 
that  thus  far  even  an  allusion  has  been  made  to  those 
which  frequently  complicate  the  puerperal  condition, 
as  mammary  engorgements,  deficient  or  excessive 
lactation  during  the  first  few  days  and  weeks  after 
delivery — the  metritis,  the  peritonitis,  the  metro-pe- 
ritonitis, the  phlebitis,  the  mammary  abscess,  &c.,  &c., 
which  are  also  liable  to  occur  to  the  puerperal  and 
nursing  female.  The  apology  for  this  apparent  omis- 
sion is  to  be  found  in  the  want  of  time  and  space,  at 
present,  to  do  them  justice.  They  may,  however, 
secure  their  due  claims  to  consideration  at  a  future 
period. 

37 


THE   OBSTETRIC   INSTITUTE 

©[F    [PMD[k3^[e)l[L[^[K]Q/^9 


TJNDER  THE  CHAEGE  OF 


JOSEPH   WARRINGTON,   M.  D. 


I.     DESIGN  OF  THE  OBSTETRIC   INSTITUTE. 

1.  To  furnish  Obstetric  aid  to  such  indigent  females  at  their 
own  homes,  as  apply  for  the  benefit  of  the  Philadelphia  Dis- 
pensary, Lying-in  Charity  and  Nurse  Society. 

2.  To  supply  practical  facilities  to  gentlemen  pursuing  the 
study  of  medicine,  for  attaining  to  present  and  future  useful- 
ness in  their  profession,  by  a  close  preliminary  training,  and  a 
subsequent  attendance  as  accoucheur  in  ordinary,  upon  those 
who  may  require  obstetric  aid  from  the  Dispensary,  &c.,  &c, 

3.  To  qualify  Nurses  for  their  especial  duties  in  the  sick- 
room, with  particular  reference  to  obstetric  cases,  and  to  im^ 
press  thera  with  a  due  sense  of  the  relation  they  hold  with  the 
Physician,  in  the  management  of  such  patients. 

II.     QUALIFICATIONS  OF  CANDIDATES  FOR  ADMISSION  INTO 
THE  INSTITUTE. 

1.  Gentlemen,  who  produce  from  a  Professor,  preceptor,  or 
some  other  responsible  person,  a  certificate,  that  they  sustain 
a  good  moral  character,  that  they  are  diligent  in  the  study 
of  Medicine,  and  that  they  have  attended  at  least  one  full 
course  of  Lectures-  included  in  the  Curriculum  of  a  degree- 
conferring  School,  are  eligible  to  admission  to  the  instructions 
and  practical  advantages  of  the  Institute, — provided  they  pro- 
cure their  tickets,  and  regularly  enter  the  class  within  five  days 
from  the  commencement  of  either  of  the  courses  of  Lectures 
indicated  in  page  443  of  this  announcement. 

2.  The  principal  reserves  the  right  to  receive  Graduates  in 
Medicine,  at  later  periods  of  the^  course,  whenever  the  coraplo- 

(435) 


436  ANNOUNCEMENT   OF 

raent  of  sixteen  pupils  has  n-ot  been  made  up  within  the  time 
specified. 

III.     ORGANIZATION   OF  THE  INSTITUTE. 

J.    WARRINGTON,  M.  D.,  Principal. 
• M.  D.,  Senior  Assistant. 

ZZHZII    ZZZZZI  I  Junior  Assistants. 

Practising  Pupils, — limited  to  sixty-four  per  annum  ;  and,  as 
nearly  as  possible,  sixteen  to  each  course. 

IV.     DUTIES  OF  PUPILS. 

1.  To  give  regular  and  punctual  attendance  upon  the  prac- 
tical instructions  of  the  Institute.  Absence  from  a  lecture 
will  require  explanation,  since  each  meeting  of  the  class  is  re- 
garded as  a  professional  appointment ;  and  no  pupil  can  be 
expected  to  have  the  management  of  actual  cases,  unless  he 
shall  have  been  present  at,  and  shared  in  all  the  practical  ex- 
ercises upon  the  models  to  the  satisfaction  of  the  Principal. 

2.  To  make  one  or  more  visits  to  the  patients  under  his  care, 
during  the  latter  periods  of  pregnancy,  to  give  such  instruc- 
tions in  relation  to  their  persons  and  positions  as  the  nature 
of  the  case  may  require :  and  promptly  to  obey  a  request  to 
attend  upon  the  labor,  unaccompanied,  except  by  the  Principal 
or  a  duly  recognised  assistant. 

3.  To  summon  to  his  aid,  at  as  early  a  period  as  practicable, 
an  assistant  or  the  Principal,  whenever  he  is  embarrassed  in 
reference  to  the  management  of  the  case  under  his  care,  espe- 
cially if  the  life  of  the  mother  or  child  is  involved  in  the 
slightest  danger. 

4.  To  inform  the  Principal  in  person  or  by  note,  of  the  de- 
livery, as  soon  as  possible  after  its  occurrence,  and  furnish  a 
summary  account  of  the  condition  of  the  mother  and  child,  at 
the  date  of  such  communication. 

5.  To  visit  his  patients  daily,  or  more  frequently  for  at  least 
five  days,  and  then  once  in  two  days  until  after  the  tenth  day 
from  the  period  of  confinement.  To  embrace  every  suitable 
opportunity  to  make  himself  acquainted  with  the  actual  condi- 
tron  of  the  puerperal  woman  and  her  child,  with  such  other 
matters  as  appertain  to  the  professional  superintendence  of  the 
affairs  of  the  nursery. 

6.  To  enter,  as  soon  as  practicable,  under  appropriate  heads, 
in  the  Tabular  Feports,  the  results  of  his  observations,  and  to 
write  at  length  a  history  of  the  case  as  observed  by  him, 
through  its  whole  progress. 

7.  To  render  to  the  Principal,  in  a  neat  and  perspicuous 
style,  the  tabular  reports,  and  a  minute  detail  of  all  the 
cases    which    have    been    under    his    care,    on  the  alternate 


THE    OBSTETRIC    INSTITUTE.  437 

pages  of  thesis  paper,  with  a   title   page  after  the  following 
manner : 

RECORD  OF  CASES 

ASSIGNED  ME    BY    DR.  WARRINGTON,   DURING    MY  CONNECTION  WITH 

THE  PHILADELPHIA  OBSTETRIC  INSTITUTE, 

IN    THE    MONTHS    OF 

,  and ,  18 

BY 


8.  And  to  return  to  the  Principal,  the  names  of  all  patients, 
whom,  with  his  consent,  he  may  decline  to  attenfd,  that  they 
may  be  distributed  to  other  members  of  the  class. 

V.     PRIVILEGES  OF  PUPILS. 

1.  To  attend  all  the  lectures  given  during  their  period  of 
engagement  in  the  practice  of  the  Institute,  besides  the  in- 
structions and  exercises  of  their  preparatory  course. 

2.  To  receive  a  Diploma,  after  the  following  form : 


€^t   (^Mttxit   SiistitutB; 


Practical   training  of  Physicians  and  Nurses  in  their  duties  to 

pregnant,  parturient,  and  puerperal  Women,  and 

their  young  children  : 

BASED    UPON 

The  Obstetric  Department  of  the  Philadelphia  Dispensary, — 
founded  in  1786  ;  the  Philadelphia  Lying-in-Charity, — in- 
corporated  in    1832;    the    Philadelphia   Nurse     So- 
ciety,— established  in  1839  ; — for  supplying  ap- 
propriate   Obstetric    Aid    to    indigent   fe- 
males at  their  own   houses. 

That M.  D., 

has  attended  full  course  of  Practical  Instructions,   

course    of  Exercise  upon  Obstetric  Models  in  my  Lecture  room, 
37* 


438  ANNOUNCEMENT   OF 

and,  under  my  supervision,  has  had  the  management  of  pa- 
tients, deriving  aid  from  the  above  Institutions  at  their  own 

houses,  during  a  period  of months. 

Joseph  Warrington,  M.  D.,  Principal. 
Philadelphia, 18 

The  above  diploma  is  granted  as  an  avrard  of  merit,  for  the 
f^xithful  discharge  of  duties  assigned  by  the  Principal,  and 
assumed  by  the  pupil. 

It  may  also  be  signed  and  sealed  by  the  President  or  a  Vice 
President  and  attested  by  the  Secretary  of  the  Lying-in- 
Charity,  in  testimony  of  the  approbation  of  the  Managers  of 
said  Charity;  Provided,  the  pupil  has  obtained  the  title  of 
M.  D.  from  a  legalized  Medical  School,  and  has  presented  to 
the  Principal  a  clinical  report  of  the  cases  that  have  been 
under  his  care,  satisfactory  to  the  principal  and  the  signing 
officer. 

It  is  neatly  executed  on  map  paper,  covering  an  area  of  about 
15  by  22  incHes,  and  involves  no  pecuniary  expense  on  the  part 
of  the  recipient,  except  w^hen  furnished  upon  parchment,  at  a 
cost  of  two  dollars. 

VI.     MANNER  IN  WHICH  THE  DIPLOMA  IS  FORFEITED. 

Neglect  of  regular  attendance  upon  the  preparatory  courses 
of  Lectures,  or  omissions  to  fulfil  the  duties  to  patients  as- 
signed by  the  Principal  and  assumed  by  the  pupil,  renders  the 
latter  liable  to  have  the  remaining  cases  withdrawn,  and  the 
Diploma  withheld,  at  the  option  of  the  Principal. 

VII.     JUNIOR  ASSISTANTS. 

{a)    Who  may  become  Junior  Assista?iis. 

Pupils  who  have  complied  with  the  regulations  of  the  Insti- 
tute during  two  terms,  consecutive,  or  nearly  so,  ma^^  become 
candidates  for  the  office  of  Junior  Assistant. 

(6)  How  they  a^e  chosen. 

Whenever  more  than  two  candidates  present  for  Junior  As- 
sistants they  shall  compete  for  the  office,  by  a  test  of  their 
qualifications  in  the  presence  of  the  Principal  of  the  Institute, 
and  two  Physicians,  nominated  by  the  Managers  of  the  Dis- 
pensary, or  of  the  Lying-in-Charity.  The  examination  shall 
be  conducted  orally  and  in  writing.  Two  negative  votes  will 
reject  the  candidate.  But  if  the  essays  be  creditable,  the  fact 
shaU  be  publicly  announced  to  the  members  of  the  Institute. 

VIII.     DUTIES  OF  THE  JUNIOR  ASSISTANTS. 

1.  Either  of  them  to  hold  himself  in  readiness  to  substitute 
the  practising  pupils,  in  attendance  upon  patients  during  their 


THE    OBSTETRIC    INSTITUTE.  439 

absence,  to  relieve  them  if  the  labor  be  so  protracted  that  they 
have  need  of  rest,  and  to  aid  them  in  any  embarrassment,  in 
the  management  of  cases  of  simple  labor. 

2.  To  apprise  the  Senior  Assistant,  or  in  his  absence,  the 
Principal,  of  the  probable  nature  of  the  case,  should  they  dis- 
cover any  thing  abnormal  in  it. 

3.  To  aid  the  practising  pupil  in  making  distinct  notes  of  the 
cases,  in  which  they  have  been  associated,  and  if  desired,  to 
fill  up  such  details  as  may  appear  to  him  to  have  been  omitted 
by  the  pupil. 

IX.    PEIVILEGES  OF  JUNIOE  ASSISTANTS. 

1.  The  Junior  Assistants  shall  have  the  privilege  of  attend- 
ing all  the  lectures  and  exercises  upon  the  models,  intended 
for  the  instruction  of  the  classes,  with  whom  they  are  asso- 
ciated. 

2.  The  fact  of  the  faithful  performance  of  their  duties,  may, 
if  desired  by  them,  be  inserted  on  their  Diplomas  over  the  sig- 
nature of  the  Principal. 

X.     SENIOR  ASSISTANT. 
{a)  Who  may  become  a  Senior  Assistant. 

1.  Pupils  who  have  received  the  Diplo^na  of  this  Institute, 
and  satisfactorily  discharged  the  duties  of  Junior  Assistants 
during  two  consecutive  terms,  may  become  candidates  for  the 
ofiice  of  Senior  Assistant. 

(&)  How  lie  is  appointed. 

2.  If  more  than  one  candidate  presents  for  the  office  of  Se- 
nior Assistant,  the  concours  shall  be  conducted  as  in  case  of 
Junior  Assistants,  except  that  the  standard  of  acquirements 
shall  be  of  a  higher  order,  in  the  case  of  the  Senior,  than  of 
the  Junior  Assistant. 

XI.     DUTIES  OF  THE  SENIOR  ASSISTANT. 

1.  To  hold  himself  at  all  times,  ready  to  respond  to  a  call 
from  a  Junior  Assistant,  either  to  aid  in  diagnosis,  respect- 
ing labor,  or  the  presentation,  or  position  of  the  child,  or  the 
necessity  of  manual  or  instrumental  aid. 

2.  To  apprise  the  Principal  immediately  on  the  occurrence 
of  any  accident,  or  in  his  absence,  either  of  the  consulting 
accoucheurs  of  the  Philadelphia  Dispensary,  whose  decisions 
in  the  case  shall  be  duly  respected. 

•  3.  To  see  that  all  such  cases  are  fully  and  regularly  re- 
corded. 

4.  To  report  daily  to  the  Principal  the  state  of  the  patients, 
in  whom  he  has  been  interested. 


440  ANNOUNCEMENT   OF 

5.  To  render  such  assistance  in  the  lecture-room  and  at 
the  exercises  of  the  practising  pupils  and  Junior  Assistants, 
on  the  models,  as  may  be  necessary. 

6.  To  attend  whenever  possible  at  the  place  of  meeting  of 
the  patients,  applicants  for  the  benefits  of  this  Institute,  and 
assist  in  the  registry  and  distribution  of  them  to  the  practising 
pupils. 

7.  To  assist,  if  required,  in  the  instruction  and  training  of 
the  Nurses  under  the  direction  of  the  Principal  and  the  mana- 
gers of  the  Philadelphia  Nurse  Society. 

8.  And  to  have  supervision  of  the  reports  of  individual 
cases  in  which  he  has  been  interested,  as  entered  in  the  record 
book,  and  see  that  the  Tabular  statements  are  properly  made 
out. 

XII.     PRIVILEGES  OF  THE  SENIOR  ASSISTANT. 

1,  The  Senior  Assistant  shall  have  the  privilege  of  control- 
ling the  judgment  and  actions  of  the  Juniors  and  practising 

f)upils,  in  regard  to  unsettled  points  of  Obstetric  practice,  un- 
css  his  views  differ  from  those  of  the  Principal  or  the  consult- 
ing accoucheurs  of  the  Philadelphia  Dispensary,  in  which  caso 
either  of  them  shall  be  the  umpire. 

2.  The  faithful  discharge  of  duty  of  the  Senior  Assistant, 
may  be  declared  upon  his  Diploma,  attested  by  the  Principal. 

XIII.     THE  PRINCIPAL 

Exercises  the  entire  supervision  of  all  cases  under  the  charge 
of  the  Institute,  and  he  alone,  or  in  conjunction  with  the 
Managers  of  the  several  corporations  on  which  it  is  based, 
holds  all  the  Assistants,  pupils,  nurses  and  patients,  amenable 
for  any  omissions  of  duty,  or  commission  of  impropriety. 

XIV.     MODE   OF  TEACHING. 

{a)  It  is  the  aim  of  the  Principal  to  make  his  instructions 
to  his  classes,  as  demonstrative  and  practical  as  possible — 
hence  part  of  each  course  is  occupied  in  a  brief  review  of  the 
Anatomy  of  the  female  organs  of  reproduction,  the  different 
pelvic  viscera,  illustrated  by  diagrams,  and  wet  preparations 
of  the  organs  removed  from  the  pelvis,  as  well  as  the  relations 
which  they  hold  to  each  other,  and  to  the  pelvis  within  which 
they  are  included  ;  the  development  of  the  uterus  for  the  ac- 
commodation of  the  ovum  ;  the  study  of  the  pelvis  as  the 
canal  through  which  the  ovum  must  pass — leading  thus  to  an 
examination  of  its  form,  axes,  diameters,  altitudes,  planes,  &c. 

(5)  The  mode  of  actionof  the  uterine  and  accessory  powerfl 
in  parturient  effort,  [labor,] — the  influences  of  the  os  uteri,  the 
vagina  and  pelvis  in  changing  the  direction  of  the  fetus,  in 
course  of  its  expulsion,  [mechanism  of  parturition,]  the  study 


THE    OBSTETRIC   INSTITUTE.  441 

of  the  different  surfaces  of  the  fetus,  and  the  mode  of  diagnos- 
ticating its  various  presentations  and  positions  at  the  upper 
part  of  the  pelvis, — the  various  deviations,  in  presentation  and 
position  of  the  fetus,  and  the  mode  of  rectifying  them,  are  all 
taught  demonstratively  and  practically  upon  the  models.  The 
Medical  and  Surgical  means  to  be  used  in  case  of  tardy,  diffi- 
cult and  impracticable  parturition  ;  as  well  as  the  various  de- 
tails of  duty  of  the  physician  and  nurse  in  the  chamber  of  the 
parturient  and  puerperal  female,  and  the  necessary  attention 
to  the  infant,  are  regarded  as  important  items  in  the  course  of 
Instructions. 

The  courses  are  so  arranged  that  by  the  time  the  minds  of 
the  pupils  have  been  fully  impressed  with  these  topics,  they 
have  opportunities  and  occasions  to  exercise  their  knowledge, 
by  attendance  upon  cases  which  are  assigned  to  their  care. 
To  relieve  them  from  the  pressure  of  such  responsibility  as  is 
incident  to  the  initial  practitioner  in  his  entrance  upon  his 
duty,  each  one  has  the  privilege  of  having  associated  with 
him  a  Junior  Assistant  of  the  Institute,  who  has  had  the  ad- 
vantage which  the  experience  of  two  previous  terms  of  prat;- 
tice  has  afforded  him,  and  who  in  turn  may  demand  the  aid  or 
experience  of  the  Senior,  who  is  in  all  cases,  expected  to  no- 
tify the  Principal,  or  a  consulting  accoucheur  of  the  Dispen- 
sary, of  any  special  difficulty.  Thus  in  some  instances  liable 
,to  occur,  the  pupil,  Junior  and  Senior  Assistants  may  be  asso- 
ciated with  the  Principal,  in  such  cases  as  require  Manual  or 
Instrumental  aid.  Observations  of  several  years  past,  have 
fully  demonstrated  the  advantage  which  the  attainment  to,  and 
exercise  of  the  office  of  Assistants  have  given  to  the  several 
successful  candidates.  Those  who  have  held  the  relation,  have 
subsequently  become  well  established  in  Obstetric  and  general 
practice  in  the  situations  in  which  they  have  located. 

(c)  The  balance  of  the  course  of  Practical  Instructions,  if 
any  time  be  left,  is  employed  in  lectures  on  such  diseases  of 
women  and  children  as  are  likely  to  engage  the  attention  of 
an  Obstetric  practitioner. 

{(])  A  portion  of  each  course  of  the  lectures  is  occupied  in 
instructing  in  their  special  and  appropriate  duties  as  nurses  to 
the  sick,  but  particularly  to  obstetric  patients,  such  women  as 
for  their  intelligence,  and  apparent  suitableness  for  the  perfor- 
mance of  their  duties  in  the  Nursery,  as  after  an  examination 
by  a  committee  of  Ladies  of  the  Nurse  Society,  have  been  re- 
commended by  tliem  to  the  instructions  and  services  of  the 
Principal  in  carrying  out  the  designs  of  the  Institute.  In 
these  instructions  the  male  members  of  the  class  participate. 

The  attention  of  gentlemen  who  reside  at  a  distance  from 
Philadelphia,  and  who  wish  to  become  connected  with  this  In- 
stitute, is  invited  to  this  circumstance,  as  it  is  strongly  probable 


442  ANNOUNCEMENT   OF 

that  it  would  advance  not  only  the  interests  of  the  Physician, 
but  that  of  the  patients  in  the  district  in  which  he  hereafter 
intends  to  settle  for  practice,  if,  during  his  stay  in  this  city  he 
could  secure  the  education  of  one  or  more  nurses,  who  would 
be  willing  to  locate  in  his  neighborhood.  Each  Nurse,  upon 
her  having  received  a  course  of  instruction  and  faithfully  at- 
tended patients  under  the  direction  of  the  Principal  and 
the  Visitors  of  the  Nurse  Society,  obtains  a  neat  certificate, 
signed  by  the  Principal  and  such  of  the  Lady  Visitors  as  are 
satisfied  with  her  performance. 

XV.     FACILITIES  FOE   IMPARTIllTa   OBSTETRIC  KNOWLEDGE. 

{a)  The  Miscellaneous  Cabinet. 

Care  has  been  taken  to  supply  the  Cabinet  with  every  va- 
riety of  means  of  illustration  which  the  counsels  of  friends  and 
pupils  at  home  or  abroad  could  suggest ;  and  they  consist  of 
mannekins,  one  of  full  size,  for  the  demonstration  of  the  pro- 
per positions  of  the  parturient  and  puerperal  female,  others  re- 
presenting the  abdomen,  pelvis,  and  thighs, — with  a  number 
of  fetuses  and  placentae,  &c.,  all  manufactured  by  the  best 
Philadelphia  Artists  in  this  department,  to  the  special  order 
of  a  late  Professor  of  Obstetrics,  and  the  Principal  himself. — 
A  great  variety  of  Obstetric  Instruments,  some  of  them  manu- 
factured by  the  late  celebrated  Botschan,  of  London,  under 
the  supervision  of  Professor  Davis, — as  well  as  by  our  Artists, 
are  kept  for  illustration  and  use.  A  standing  order  is  in  the 
hands  of  one  of  our  most  extensive  Surgical  Instrument 
Makers,  to  supply  the  Cabinet  with  a  specimen  of  every  im- 
provement or  new  invention  of  importance  in  this  department. 

(b)  ■  The  Anatomical  Cabinet 

(Contains  many  specimens,  illustrative  of  the  Anatomy,  Physi- 
ology and  Pathology  of  the  generative  apparatus,  including  a 
series  of  ova  and  fetuses,  from  the  earliest  stage  up  to  the 
complete  intra-uterine  development.  Constant  accessions  are 
being  made  to  this  part  of  the  means  of  illustration,  and  the 
Principal  avails  himself  of  this  opportunity,  gratefully  to  ac- 
knowledge the  kindness  of  several  of  his  pupils  and  friends, 
in  presenting  to  him  a  number  of  valuable  specimens.  He, 
moreover,  cherishes  the  hope  that,  either  in  their  private  rela- 
tions, or  as  members  of  the  Obstetric  Society,  not  only  his 
former,  his  present,  but  his  future  pupils  will,  as  opportunities 
offer,  and  inclinations  prompt,  continue  their  favors,  that 
thereby  the  materials  for  thorough  instruction  by  this  species 
of  demonstration,  may  become  complete. 

(c)  The  Pictorial  Cabinet. 

The  drawings  used  in  aid  of  the  practical  instructions,  are 


THE    OBSTETRIC    INSTITUTE.  443 

numerous,  and  can  be  so  arranged,  as,  in  conjunction  with  the 
wet  preparations  and  the  models,  to  make  a  strong  impression 
upon  the  understanding  of  the  pupils.  They  are  mostly 
colored  after  nature,  and  hold  a  definite  relation  to  the  size  of 
the  adult  and  fetal  subjects.  The  dimensions  of  each  figure 
are  such,  that  it  can  be  readily  seen  from  any  point  of  the 
room  occupied  by  the  class. 

XVI.     TIME  DEVOTED  TO  LECTUEES. 

1.  The  regular  courses  of  Practical  Instructions  in  Obstetric 
Medicine,  commence  on  the  14th  of  February — 6th  of  May— 5th 
of  September — and  24th  of  November,*  of  each  year,  provided, 
that  when  these  dates  fall  on  Sabbath,  the  first  lecture  of  the 
course  will  be  given  on  the  following  Monday.  Each  Course 
continues  about  10  weeks,  and  includes  60  lessons,  not  only  on 
the  great  principles  of  the  Science,  but  the  practical  details  of 
the  Art  of  Obstetric  Medicine — and  these,  when  the  pupil  is 
believed  to  be  prepared,  are  verified  by  opportunities  of  ob- 
serving cases.  The  members  of  each  class,  formed  at  the  com- 
mencement of  the  Course,  have  in  regular  rotation,  the  patients 
of  the  Dispensary,  Lying-in-Charity  and  Nurse  Society  as- 
signed them  for  their  care  and  attendance,  with  the  aid  of  the 
assistants,  if  necessary,  and  under  the  supervision  of  the  Prin- 
cipal. 

2.  The  term  of  engagement  in  the  practice  in  connection 
with  each  course  of  instruction  is  about  three  months — a^d 
commences  on  the  16th  of  April,  16th  of  July,  16th  of  October  and 
16th  of  January,  of  each  year. 

XVII.     FEE. 

1.  For  each  pupil,  thirty  dollars,  money  current  in  the  banks 
of  Philadelphia,  to  be  paid  on  entrance  to  either  of  the  courses 
of  instructions  and  practice. 

2.  The  payment  of  fifty-five  dollars  upon  first  entrance,  secures 
to  the  pupil  the  privilege  of  attending  two  consecutive  courses 
of  instructions  and  practice,  by  which  he  may  become  eligi- 
ble to  promotion  to  the  offices  of  Junior  and  Senior  Assistants, 
agreeably  to  Articles  VII.  and  IX.  of  this  announcement. 

The  pupils  attaining  to  these  offices,  are  exempted  from 
any  other  payment  of  fees  for  their  connection  with  the  In- 
stitute. 

XVIII.     SUCCESS  OF  THE  INSTITUTE. 

The  Obstetric  Institute  was  commenced  in  June  1837,  and 
since  that  time  the  Principal  has  given  four  courses  each  year 

*  The  daily  lessons,  since  1847,  continue  to  be  given  at  a  quarter  before  7,  and 
terminate  at  a  quarter  before  8,  A.  M.— and  therefore  do  not  interfere  with  any 
other  public  or  private  courses  in  the  city. 


444  ANNOUNCEMENT   OF 

to  advanced  pupils  or  recent  graduates  in  Medicine,  who  had 
attended  under  his  supervision  many  hundred  Obstetric  cases, 
some  of  whose  histories  have  been  carefully  recorded,  and  in 
the  aggregate  supply  a  considerable  amount  of  material  for 
clinical  illustration  inr  the  preparatory  courses.  In  his  ardu- 
ous and  responsible  enterprise  of  preparing  the  Medical  Stu- 
dent for  entering  upon  the  practical  duties  of  the  accoucheur, 
through  the  portals  of  Obstetric  experience,  the  Principal  has 
been  occasionally  cheered  by  concurrent  testimonies  of  many 
former  pupils,  distributed  throughout  various  sections  of  our 
extended  country,  respecting  the  value  of  these  courses  of  in- 
struction, as  contributing  essentially  to  their  success  in  obtain- 
ing practice  as  Physicians.  Young  gentlemen  who  are  ambi- 
tious to  superadd  to  the  knowledge  they  may  acquire  from 
books  and  their  Professors,  the  practical  advantages  which  may 
be  obtained  by  a  full  compliance  with  the  disciplinary  regula- 
tions of  the  Obstetric  Institute,  are  not  only  brought  more  or 
less  before  the  notice  of  thirty-six  gentlemen,  twelve  of  whom 
are  Managers  of  the  Philadelphia  Dispensary :  twenty-four 
Officers  and  Directors  of  the  Philadelphia  Lying-in-Charity : 
and  twenty-eight  Ladies,  Visiting  Managers  of  the  Nurse  So- 
ciety, who  give  personal  attention  to  a  large  number  of  pa- 
tients deriving  the  benefits  of  the  Institute,  but  by  the  exer- 
cise of  their  daily  duties  towards  the  patients  under  their  care, 
and  their  almost  constant  relation  with  intelligent  Nurses,  se- 
lected by,  and  in  .  the  employment  of  the  Society  of  Ladies, 
they  are  in  a  marked  degree  prepared  to  perform  the  functions 
of  Physicians,  in  the  neighborhoods  in  which  they  settle  for 
practice,  with  a  business-like  manner  which  inspires  the  confi- 
dence of  their  patients  in  their  professional  abilities. 

As  this  plan  hererein  described,  contemplates  a  succession 
of  elevations  in  office  from  that  of  Pupil  up  to  Senior  Assist- 
ant Obstetric  Physician  in  this  Institute,  the  wish  is  hereby 
expressed,  and  the  hope  entertained  by  the  Principal,  that  in 
the  event  of  his  death  or  resignation,  the  Boards  of  Managers 
of  the  several  co-operative  Institutions,  which  have  through  the 
intervention  of  the  present  Principal  been  concentrated  upon 
this  school,  will  elect  a  successor  from  amongst  those  who 
shall  have  attained  to  the  stations  of  Senior  Assistant, — and 
that  this  election  shall  proced  upon  the  same  ground  as  that 
adopted  in  relation  to  Junior  and  Senior  Assistants. 


OBSTETRIC  SOCIETY 

•In  1843  several  members  of  the  class  organized  themselves 
into  an  Association,  for  mutual  improvement  in  Obstetric  Me- 
dicine.    They  constituted  the  Principal  their  President,  with 


THE   OBSTETRIC   INSTITUTE.  445 

whom  the  Constitution  and  By-Laws  are  deposited.  A  number 
of  interesting  and  instructive  communications  have  been  read 
at  its  meetings. 

The  plan  of  the  Society  is,  that  it  consists  of  President,  Se- 
cretary, Resident  Members,  Corresponding  or  Non-resident 
Members,  Fellows  and  Honorary  Members. 

Gentlemen  desirous  of  connecting  themselves  with  the  Ob- 
stetric Institute,  can  apply  to  Dr.  Warrington,  at  his  resi- 
dence. No.  229  Vine  Street,  Franklin  Square,  from  2  to  3,  or 
6  to  7,  P.  M. 


Note. — It  is  desirable,  that  the  four  classes  in  the  year 
should  be  as  nearly  equal  in  size  as  possible,  since  there  is 
nearly  the  same  amount  of  Clinical  practice  for  each  class.  It 
is  also  desirable,  that  each  class  should  be  in  even  numbers, 
since  the  models  and  apparatus  for  practical  instruction  in  the 
lecture-room  are  so  arranged,  as  that  the  members  of  each  class 
work  best  in  pairs. 

It  is  suggested,  that  the  courses  which  commence  in  Sep- 
tember and  November,  are  best  adapted  to  the  wants  of  those 
who  resort  to  Philadelphia  principally  for  Clinical  experience, 
while  those  of  February  and  May  are  especially  convenient 
for  such  gentlemen  as  have  leisure  to  devote  to  practical  Ob- 
stetrics, only  in  the  intervals  of  the  first  and  second  courses 
of  instruction  in  the  degree-conferring  schools. 

Note. — Dr.  Elwood  Wilson,  505  Mulberry  Street,  continues 
to  hold  the  oflSce  of  Senior  Assistant,  a  post  at  which  he  has 
arrived  through  the  medium  described  in  the  preceding  pages 
of  this  announcement. 

Note. — Since  the  establishment  of  this  Institute  two  thou- 
sand and  one  hundred  patients  have  been  assigned  to  the 
attentions  of  more  than  three  hundred  young  gentlemen,  who 
had  complied  with  the  disciplinary  regulations  which  govern 
it.  The  number  of  cases  has  been  rapidly  increasing  during 
the  several  years  last  past;  and  as  the  Obstetric  department 
of  the  Dispensary  is  coextensive  with  that  of  the  Lying-in 
Charity  and  Nurse  Society,  extending  at  present  to  the  supply 
of  applicants  for  its  aid  from  all  the  populous  portions  of 
Philadelphia  and  its  districts,  the  limitation  of  the  size  of  the 
classes  will  be  withdrawn  in  proportion  to  the  extension  of  the 
operations  of  thft  concern. 


BOOKS 

PUBLISHED  AND  FOR  SALE  BY 

BARRINGTON  &  HASWELL, 

NO.    87    NORTH     SIXTH     STREET,     PHIL. ADELPHIA. 


Ajtdral's  Medical  Clinic  :  3  vols. 

■  ■  Diseases  of  the  Encephalon. 
Diseases  of  the  Abdomen. 

■  Diseases  of  the  Chest. 
Abaij 's  Practical  Manual  on  Diseases 

of  the  Heart  and  Great  Vessels. 
Translated  from  the  French,  by 
Wm.  A.  Harris,  M.  D.,  U.  S.  N. 

Arktjeus  on  the  Causes  and  Signs 
of  Acute  Diseases,  and  Schill's  Out- 
lines of  Pathological  Semeiology. 

Bampfi  eld  on  Curvatures  of  the  Spine. 
Including  all  the  Forms  of  Spinal 
Distortion,  Vi^ith  additions,  by  John 
K.  Mitchell,  M.  D.,  Professor  of  the 
Practice  of  Medicine  in  the  Jeffer- 
son Medical  College. 

Beh  &  Stokes's  Lectures  on  the 
Theory  and  Practice  of  Physic. 
4th  American  edition,  2  vols.  8vo. 
much  enlarged  and  improved.  ' 

Bell  on  Baths  and  Bathing,  in  their 
Hygienic  and  Therapeutic  Appli- 
cations, with  copious  details  on  the 
Watery  Regimen,  demi-8vo. 

Bell's  Materia  Medica. 

Blundell's  Midwifery — embracing 
the  Principles  and  Practice,  a  new 
edition,  edited  by  C.  Severn,  M.  D, 

BuRjfE  on  Habitual  Constipation — 
its  Causes  and  Consequences. 

Christison  on  Poisons  in  relation  to 
Medical  Jurisprudence,  Physiology 
and  the  Practice  of  Physic. 

Clark  on  the  Sanative  Influence  of 
Climate. 

Cooper's,  Sir  A.,  Lect.  on  Surgery. 

CoLLES. — Course  of  Lectures  on  Sur- 
gery, delivered  in  the  Royal  (college 
of  Surgeons,  by  Abraham  CoUes, 
M.  D.,  for  thirt^'-four  years  Profes- 
sor of  Surgery  in  the  Dublin  Col- 
lege. From  Notes  collected  and 
repeatedly  revised  by  Simon  M'- 
Coy   Esq.,  F.  R.  C.  S.  I. 


Colby's  Practical  Treatise  on  the 
Diseases  of  infants  and  children. 

Davidson  and  Hudson  on  fever. 

Diseases  of  the  Uterus,  by  Weller, 
Lisfranc,  and  Ingleby. 

Epidemics  of  the  Middle  Ages,  viz. ; 
the  Black  Death,  and  Dancing  Ma- 
nia, from  the  German  of  Hecker. 

EvA]yso3ir  and  Maun  sell  on  the  Man- 
agement and  Diseases  of  Children, 
edited  by  D.  F.  Condie,  M.  D. 

Fox  &  Harris  on  the  Human  Teeth. 
A  large  super-royal  octavo  volume, 
with  30  pages  of  lithographic  en- 
gravings. 

FoRDTCE  on  Fever.  Second  Ameri- 
can edition,  with  an  Introduction. 

Gerhard  on  the  Chest. 

GiBERT  on  the  Changes  of  the  Blood, 
translated  by  John  H.  Dix,  M.  D. 

Gooch's  Midwifery,  8vo.  4th  Am.  ed. 

GoocH  on  Diseases  of  Women  and 
Children,  2nd  edition,  with  engs. 

Graves's  System  of  Clinical  Medi- 
cine, with  Notes  and  Additions  by 
W.  W.  Gerhard,  M.  D.,  3d  Ameri- 
can ed.  revised  and  greatly  enlarged. 

Gross's  Pathological  Anatomy.  A 
new  edition,  thoroughly  revised  and 
greatly  enlarged,  illustrated  with 
nearly  250  engs.  on  wood,  and  50 
figs,  colored,  on  Uthographic  plates. 

Harlan's  Gannal  on  Embalming. 

Heberden's  Commentaries  on  the 
History  and  Cure  of  Diseases, 

Holland's  Medical  Notes  and  Re- 
flections. 

Horner's  Medical  and  Topographical 
Observations  upon  the  Mediterra- 
nean, and  upon  Portugal,  Spain, 
and  other  countries,  illustrated  with 
engravings. 

HuNTKR  on  the  Blood,  Inflammation, 
and  Gunshot  Wounds,  with  eng's. 

on  the  Teeth.  With  eng's. 


(447) 


BARRINGTON   AND    HASWELL's    CATALOGUE. 


HuxTER    on  the    Venereal    Disease. 

With  engravings. 

on  the  Animal  CEconomy. 

's  Principles  of  Surgery. 

— — — 's  Life.     By  Drewry  Ottley. 

— — — 's  Complete  Works,  edited  by 
James  F.  Palmer,  Senior  Surgeon 
to  the  St.  George's  and  St.  James's 
Dispensary,  &c.  With  numerous 
engravings.     4  vols.,  8vo. 

Institutes  of  Surgery.  By  Sir  C.  Bell. 

Latham's  Lectures  on  subjects  con- 
nected vs^ith  Clinical  Medicine : 
comprising  Dis.  of  the  Heart. 

Latham's  Medical  Clinic,  comprising 
Semeiology   and    Auscult.  2d  ed. 

Laxcock's  Essay  on  Hysteria.  With 
numerous  Illust.  and  Curious  Cases. 

Lkk's  Theory  and  Practice  of  Mid- 
wifery. Illust.  vv^ith  numerous  eng's. 

Liston's  Elements  of  Surgery,  4th 
American  from  the  last  London  edi- 
tion, with  upwards  of  160  illustra- 
tive Engravings.  Edited  by  Samuel 
D.  Gross,  M.  D.,  Professor  of  Sur- 
gery, Louisville  Medical  Institute  ; 
Author  of  Elements  of  Pathological 
Anatomy,  &c.,  &c. 

LiTTKLL  on  Diseases  of  the  Eye. 

London  Dissector,  or  Guide  to  Ana- 
tomy, for  the  use  of  Students  ;  from 
the  last  London  ed.,  edited  by  J. 
Chaisty,  M.  D. 

MACAiiTivEr  on  Inilammation. 

MACROBiif's  Introduction  to  the  study 
of  Practical  Medicine. 

Marshall's  Practical  Observations 
on  Diseases  of  the  Heart,  Lungs, 
Stomach,  Liver,  &c. — Weatherhead 
on  Diseases  of  the  Lungs ;  consi- 
dered especially  in  relation  to  the 
particular  Tissues  affected,  illustra- 
ting the  different  kinds  of  Cough. 
In  1  vol. 

Millikren's  Aphorisms  on  Insanity 

Minor  Surgery ;  or,  Hints  on  the 
Every-day  Duties  of  the  Surgeon. 
Third  edition,  with  numerous  ad- 
ditions. Illustrated  by  247  engra- 
vings. By  H.  H.  Smith,  M.  D. 
Assistant  Lecturer  on  Clinical  Sur- 
(448) 


gery  in  the  University  of  Pennsyl 
vania,  Lecturer  on  Minor  Surgery, 
Fellow  of  the  College  of  Physicians, 
Member  of  the  Philadelphia  Medi- 
cal Society. 

Neill's  Outlines  of  the  Arteries,  with 
short  Descriptions  ;  Designed  for  the 
Use  of  Medical  Students.  2d  edi- 
tion.    Colored  engravings. 

Neill's  Outlines  of  the  Nerves,  with 
short  Descriptions  :  Designed  for 
the  Use  of  Medical  Students.  En- 
gravings, 2d  edition. 

Neill's  Outlines  of  the  Veins  and 
Lymphatics :  Designed  for  the  Use 
of  Medical  Students.  Col'd.  engs. 

Neill's  Outlines  of  the  Arteries, 
Nerves,  Veins,  and  Lymphatics.  3 
vols,  in  one,  (the  complete  series.) 

Nunnblex's  Treatise  on  the  Nature, 
Causes,    and  Treat,  of  Erysipelas. 

Pettigrew  on  Superstitions  con- 
nected with  the  History  and  Prac- 
tice of  Medicine  and  Surgery. 

PiLCHER  on  the  Structure,  Economy, 
and  Diseases  of  the  Ear.  With  nu- 
merous beautiful  engravings. 

Practical  Medicine.  .  Illustrated  by 
Cases  on  the  most  important  Dis- 
eases.     Edited  by  J.  M.  Galt,M.  D. 

Schill's  OutUnes  of  Pathological  Se- 
meiology, and  Areta)us  on  the 
Causes  and  Signs  of  Acute  Disease. 

ScuDAMORE  on  the  Nature  and  Cure 
of  Gout  and  Rheumatism. 

Tamplin's  Lectures  on  the  Nature 
and  Treatment  of  Deformities,  with 
nearly  70  Engravings  on  wood. 

Thomsox  and  Twining  on  Diseases 
of  the  Liver  and  Biliary  Passages, 
and  of  the  Spleen. 

Thomson  on  Inflammatory  Affections 
of  the  Internal  Organs,  and  Mal- 
colmson  on  Liver  Abscess. 

Unherwood  on  Children.  With 
Notes  by  Drs.  S.  Merriman  and 
Marshall  Hall  and  John  Bell. 

Willis  on  Urinary  Diseases,  and 
their  Treatment. 

Warrington's  Obstetric  Catechism, 
150  eng's.  and  2347  Ques.  &  Ans. 


14  DAY  USE 

RETURN  TO  DESK  FROM  WHICH  BORROWED 

BIOLOGY  LIBRARY 

TEL.  NO.  642-2532 

This  book  is  due  on  the  last  date  stamped  below,  or 

on  the  date  to  which  renewed. 

Renewed  books  are  subject  to  immediate  recall. 

-^U€ — 


OCT  1 0  1963 


'■'-^81983 


OCT  15 '969     9 


OCT  0     1970 


SANTA  BARBARA 


INTERLI3RARY 


LOAN 


14  PAYS  AFTER  RfC^m 


/^^^ 


SEP  81  1970 


ucr^thfir 


■  Hoyet)  iHiMm,^ 


LD21A-12»>1-5,'61 
(J401sl0)476 


General  Library 

University  of  California 

Berkeley 


/ 


•'4i— ' 


U.C.  BERKELEY  LIBRARIES 


CD3^7Dtflba 


